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UNITED STATES OF AMERICA 




WASHINGTON, D. C. 



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FIRST LINES , 

PRACTICE OF PHYSIC. 

BY 

WILLIAM OULLEN, M. D. 

V 

LATE PROFESSOR OF THE PRACTICE OF PHYSIC, IN THE UNIVERSITY OF 
EDINBURGH, &c. &c. 

WITH 

NOTES AND OBSERVATIONS, 

PRACTICAL AND EXPLANATORY, 

V PRELIMINARY DISCOURSE, 

IN DEFENCE OF CLASSICAL MEDICINE, 

AND 

AN APPENDIX, 
By CHARLES CALDWELL, M. D. 

PROFESSOR OF THE INSTITUTES OF MEDICINE IN TRANSYLVANIA UNIVERSITY, 

SECOND EDITION, REVISED AND ENLARGED. 
IN TWO VOLUMES, 

VOL. I. 



PHILADELPHIA: 

PUBLISHED BY EDWARD PARKER, 
No. 178 MARKET-STREET. 

William Urovm, Printer. 
1822. 



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District of Pennsylvania, to wit: 
*»*»**. BE IT REMEMBERED, That on the twenty-fourth day of Au- 
J seal.; gust, in the forty-seventh year of the Independence of the United 
••••••• states of America, A D. 1822, Edward Parker, of the said dis- 
trict, hath deposited in this office the title of a book, the right whereof he 
claims as Proprietor, in the words following, to wit: 

"First Lines of the Practice of Physic. By William Cullen, M. D. Late 
Professor of the Practice of Physic, in the University of Edinburgh, 
&c. See. With Notes and Observations, Practical and Explanatory, a 
Preliminary Discourse, in Defence of Classical Medicine, and an Ap- 
pendix, by Charles Caldwell, M. D. Professor of the Institutes of Medi- 
cine in Transylvania University. Second edition, revised and enlarged. 
In Two Volumes. Vol. I." 

In conformity to the act of the Congress of the United States, intituled, 
" An act for the encouragement of learning, by securing the copies of maps, 
charts, and books, to the authors and proprietors of such copies, during the 
times therein mentioned." And also to the act, entitled, " An act supple- 
mentary to an act, entitled, ' An act for the encouragement of learning, by 
securing the copies of maps, charts, and books, to the authors and pro- 
prietors of such copies during the times therein mentioned,' and extending 
the benefits thereof to the arts of designing, engraving, and etching histori- 
cal and other prints." *' 

D. CALDWELL, 

Clerk of the District of Pennsylvania 



ADVERTISEMENT 

BY THE EDITOR. 

The first volume of the present edition is 
not very greatly enlarged by original matter, 
but tlie amount of notes we have added to the 
second is considerable. Being partly disquisi- 
tive and partly practical, we are not without 
the hope, that, to most readers, these will be 
found interesting and useful. On the score of 
principle, we have stated nothing Avhich we do 
not consider susceptible of defence, nor any 
thing in relation to practice, which is not sanc- 
tioned by ample experience. 

But, perhaps, the most valuable additions we 
have made will be found in the Appendix, which 
is ample, and the greater part of which is ex- 
tracted from authors of reputation. 

It will be discovered by the reader, that se- 
veral opinions advanced in these extracts, are at 
variance with those which we ourselves have 
hitherto maintained on the same subjects. It is 
not to be hence inferred that we have abandoned 
our ground. Far otherwise. Our views continue 
the same as formerly. But being friendly to 
liberal discussion, and having no wish to pro- 



iv ADVERTISEMENT. 

pagate opinions that are not supported by solid 
argument, and which cannot bear the shock of 
investigation, we felt ourselves called on by a 
spirit of candour, to admit freely into this work, 
which will be read chiefly by the young and 
the inquiring, the sentiments of able and dis- 
tinguished writers, however different they may 
be from our own. 

Our object being exclusively the inculcation 
of truth, we would rejoice in the attainment of 
so important an end, even by employing the 
means furnished by others to correct or eradi- 
cate our own errors. 



Philadelphia, > 
June 15th, 1822-5 



CONTENTS 

OF 

THE FIRST VOLUME. 



PAGE 

DEDICATION, ix 

Preface by the Editor, ------- x i 

Preface by the Author, 1 

Preliminary Discourse, by the Editor, 27 

Tabular view of Cullen's Synopsis, - - - - 71 
Introduction, - - --'--',-■ .83 

PART I. 

Of Pyrexia, or Febrile Diseases, .... 87 

BOOK I. 

Of Fevers, - - - - - - 87 

Chap. I. Of the Phenomena of Fevers, - - 87 

II. Of the Proximate Cause of Fever, - - 99 

III. Of the Difference of Fevers, and its causes, 122 

IV. Of the Remote Causes of Fevers, - - 131 
V. Of the Prognosis of Fevers, - - 143 

VI. Of the Method of Cure in Fevers, - - 154 

Sect. I. Of the Cure in Continued Fevers, - 154 

II. Of the Cure of Intermittent Fevers, 194 

BOOK II. 

Of Inflammations, or Phlegmasia, J- - - - 20G 

Chap. I. Of Inflammation in genera* ... 200 

Sect. I. Of the Phenomena of Inflammation, - - 200 

II. Of the Proximate Cause of Inflammation, - 204 

III. Of the Terminations of Inflammation, - 212 

IV. Of the Remote Causes of Inflammation, - 218 

V. Of the Cure of Inflammation, ... 220 
Chap. II. Of Inflammation, more strictly Cutaneous, - 224 

III. Of Ophthalmia, or Inflammation of the Eye, 227 

IV. Of Phrensy, or Phrenitis, 232 

V. Of the Quinsy, or Cynanche, ... 235 

Sect. I. Of the Cynanche Tonsillaris, ... 236 

II. Of the Cynanche Maligna, - - - 238 



vi CONTENTS. 

PAGE 

Sect. III. Of the Cynanche Trachealis, ' - - -243 

IV. Of the Cynanche Pharyngaea, 

V. Of the Cynanche Parotidaea, - - - 249 
Chap. VI. Of Pneumonic Inflammation, - - - '- 250 

VII. Of Peripneumonia Notha, or Bastard Peripneu- 

- 270 

mony, - - *iv 

VIII. Of the Gastritis, or Inflammation of the Stomach, 276 
IX. Of the Enteritis, or Inflammation of the Intes- 
tines, ..-----• 283 
X. Of the Hepatitis, or Inflammation of the Liver, 285 
XI. Of the Nephritis, or Inflammation of the Kid- 
neys, - 291 

XII. Of the Rheumatism, 295 

XIII. Of the Toothach, or Odontalgia, - - 312 

XIV. Of the Gout, 319 

BOOK III. 

Of Exanthemata, or Eruptive Fevers, ... 355 

Chap. I. Of the Small-Pox, - 356 

II. Of the Chicken-Pox, 383 

III. Of the Measles, 384 

IV. Of the Scarlet Fever, - - - - 391 

V. Of the Plague, 397 

Sect. I. Of the Phenomena of the Plague, - - 397 

II Of the Prevention of the Plague, - - 401 

III. Of the Cure of the Plague, - - - 405 

Chap. VI. Of Erysipelas, or St. Anthony's Fire, - - 408 

VII. Of the Miliary Fever, .... 413 

VIII. Of the remaining Exanthemata :— Urticaria, 

Pemphigus, and Aphtha, ... 422 

BOOK IV. 

Of Hjemorrhagies, ----.__ 426 

Chap. I. Of Haemorrhagy in general, ... 426 

Sect. I. Of the Phenomena of Haemorrhagy, - . 428 

II. Of the Proximate Cause of Haemorrhagy, - 430 

III. Of the remote Causes of Haemorrhagy, - 445 

IV. Of the Cure of Haemorrhagy, - *" - - 447- 
Chap. II. Of the Epistaxis, or Haemorrhagy of the Nose, 457 

III. Of the Haemoptysis, or Haemorrhagy from the 

Lungs, - - - - - . . 464 

Sect. I. Of the Phenomena and Causes of Haemoptysis, 464 
II. Of the Cure of Haemoptysis, - - . 470 
Chap. IV. Of the Phthisis Pulmonalis, or Consumption of 

the lungs, ...... 472 

Sect. I. Of the Phenomena and Causes of the Phthisis 

Pulmonalis, ----.. 472 

II. Of the Cure of Phthisis, - 493 



CONTENTS. v ii 

PAGE 

Chap. V. Of the Haemorrhois, or of the Haemovrhoidal 

Swelling and Flux, 505 

Sect. I. Of the Phenomena and Causes of the Haemor- 
rhois, 505 

II. Of the Cure of Hemorrhoidal Affections, - 513 

APPENDIX. 

Intermittent Fevers, „j 

Remittent Fever, ----.__ x 

Synochus, or Simple Continued Fever, - xv 

Typhus Mitior, or Nervous Fever, - xxv 

Typhus Gravior, or Malignant Putrid Fever, - - xxxix 

Phlegmon, lj v 

Erysipelas, Ixvii 

Phrenitis, or Inflammation of the Brain and its Mem- * 

branes, Ixviii *S 

Ophthalmia, or Inflammation of the Eye, - - Ixviii 
Cynanche Trachealis, or Croup, - - - lxxxii 

Hepatitis, or Inflammation of the Liver, - - - xc 



TO 

NATHANIEL CHAPMAN, M. D. 

PROFESSOR OF THE INSTITUTES AND PRACTICE OF ME- 
DICINE, AND OF CLINICAL PRACTICE, IN THE 
UNIVERSITY OF PENNSYLVANIA. 

DEAR SIR, 

IN addition to the gratification which the act affords 
me, the highest I could experience on such an occa- 
sion, there is a peculiar propriety in my prefixing your 
name to the following pages. 

For whatever benefit the physicians and students of 
medicine of the United States may derive from the part 
I have performed in preparing this work for the press, 
it is fit they should know, that they will be as much in- 
debted to you, as to myself. Although the labour has 
been mine, that labour would not have been under- 
taken, but for your advice and proffered patronage. 

Placed, moreover, at the bead of that department of 
medicine, to which this work especially belongs, you 
not only possess the highest qualifications to judge of 
the value of the additions I have made; but, publicly to 
express your opinion respecting them, will constitute a 
part of your official duty. Your approbation, already 
so flatteringly signified, by adopting the present edition, 

vol. i. b 



X DEDICATION. 

as the text-book to your lectures, will be its surest 
passport to public favour. 

But, in thus addressing you, I am actuated by other, 
and, to myself, more highly interesting motives. 

Pleased at your advancement in prosperity and re- 
putation, and cherishing a lively sense of the tru>h and 
steadiness of your friendship towards myself, I em- 
brace, with eagerness, this opportunity of publicly ex- 
pressing to you my joy at the one, and the high estima- 
tion in which I hold the other. Nor should 1 either 
be just to my own feelings, or stand acquitted of my 
duty to you, were I to neglect the occasion which now 
presents itself, of declaring my unqualified admiration 
of your talents and skill, as a teacher and a practi- 
tioner, and my exalted esteem for your virtues as a 
man. 

While delicacy towards your feelings prohibits me 
from saying more, a sentiment of justice to your merit 
forbids me to say less. Whether I may have found 
the proper medium or not, of this I am confident, that 
no one, acquainted with you, will accuse me of dealing 
in exaggerated praise. 

That your life may be long, illustrious, and happy, 
and your example an object of honourable emulation 
to the physicians of America, is the sincere wish of, 
Dear Sir, 

Your obliged Friend, and 

Obedient Servant, 

CHARLES CALDWELL. 

Philadelphia, November 1, 1816. 



PREFACE BY THE EDITOR 



THE elaborate preface, by Dr. Cullen himself, being 
sufficiently explanatory of the text of his " First Lines," 
nothing further is incumbent on us, than to assign a 
reason for the Discourse we have prefixed, and the 
Notes we have added. In the performance of this duty, 
it shall be our aim, to observe as much conciseness, as 
may be consistent with perspicuity. 

To those, who, for the last twenty years, have been 
conversant with the history of medicine in the United 
States, it is perfectly known, that a bold and persever- 
ing attempt was made, by the late Dr. Rush, to over- 
throw entirely Methodical Nosology, and erect, on its 
ruins, his favourite hypothesis of the Unity of Disease. 
Nor was he altogether unsuccessful, in the pursuit of 
his enterprise. By a combination of popular and im- 
posing qualities, superadded to an ascendency, derived 
from his station, as a public teacher, he implanted in 
the minds of no inconsiderable portion of the physicians 
of America, a disbelief in the truth and value of classi- 
cal medicine. 

To endeavour to counteract this evil, which, from 
the simplicity it appeared to have introduced into me- 



Xii PREFACE BY THE EDITOR. 

dical science, and the facility it was supposed to give 
in acquiring the knowledge of it, had become exceed- 
ingly seductive of indolent minds; to recall the preva- 
lence of correct principles, touching the subdivisions 
and classification of disease, and to restore to our pro- 
fession the advantages of system, constitute the object 
of our preliminary discourse. 

How far we may have succeeded in our aim, it does 
not belong to us to determine. On this, as on all other 
points, the intelligent reader is honestly invited to judge 
for himself. We will be permitted, however, to ob- 
serve, that, in our discussion of the subject, we have 
attempted nothing, on the influence of precedent, or by 
the weight of authority. Our sole reliance is on the 
ground of argument and legitimate analysis. Nor do 
we mean to arrogate any superiority to ourselves, but to 
our cause, in saying, that, on that ground, we will en- 
counter, with a confidence of success, any opposition 
that can be arrayed against us. 

In our very limited corrections of his nosological ar- 
rangement, we have endeavoured to tread lightly on the 
ashes of Dr. Cullen. His system abounds in error. 
We have presented a tabular view of it, for two 
reasons. It is, in the main, less exceptionable, than 
any other, now extant: and it is the system pursued in 
his First Lines of Practice. We have noticed only a 
few of its most prominent faults, passing the minor 
ones without remark. 

How long it may be, before a more correct scheme 
of nosology shall be prepared, we cannot predict. The 



PREFACE BY THE EDITOR. xiii 

object is practicable, and will, certainly, be achieved. 
Nor are we without a lively hope, that the honour of the 
enterprise will belong to our own country: for, how- 
ever strangely the declaration may sound, in some 
places abroad, or offensively, in others, we are con- 
vinced, from an examination of evidence, to which 
credit seems due, that there exists, in the medical 
mind of the United States, a degree of boldness, 
originality, and vigour, which have at present no pa- 
rallel, in the minds of the physicians of the old 
world. If, then, to the intellectual endowments, which 
a beneficent and bounteous Creator has conferred on 
them, and the unlimited field of observation he has 
given them to enjoy, the physicians of America add, 
what cultivation and industry are calculated to bestow, 
the result cannot fail to be eminently honourable to 
themselves and their country; and no less advantageous 
to the human race. 

In our notes to the present edition of Cullen's First 
Lines, our object has been to elucidate obscurities, 
correct errors, and supply deficiencies: to bring the 
work, in point of principle, from the period at which 
it was written, through the progressive improve- 
ment in science, up to the present time; and, by mould- 
ing it into a system of American practice, to render 
it better suited to the instruction of students of me- 
dicine, and inexperienced practitioners, in the United 
States. 

That there existed ample grounds, and cogent rea- 
sons, for such an undertaking, cannot be denied. 



x iv PREFACE BY THE EDITOR. 

" The First Lines of Practice," as they came from 
the pen of their illustrious author, constitute a work 
of inequalities and contrasts; marked by excellencies, of 
a superior order, intermingled with imperfections both 
numerous and great Like most other productions of 
superior intellect, their good and bad qualities are on 
the same scale. 

The histories and descriptions of diseases, with 
which this work presents us, are confessedly unrivalled. 
Nor ought less, perhaps, to be said of many of its ex- 
positions of the indications of cure: they, also, are 
clear, pertinent, and accurately drawn, beyond what 
is to be found in any other publication with which we 
are acquainted. 

In addition to this, the entire work, notwithstanding 
its defects, is comprehensive, in its outline, and much 
more classical and systematic, in its plan, than any other 
of the kind that has hitherto appeared. With Thomas's 
Practice of Physic, which is nothing but a compilation, 
it would be injustice to compare it. Much of the most 
valuable matter contained in that work will be found 
in the Appendix to the present edition. 

For these reasons, the work of Cullen has been long 
used, in Great Britain and A merica, as a tex-tbook for 
teachers; and has been uniformly placed in the hands 
of students of medicine, as their best scientific and 
practical guide. 

But, in this country, its faults have been considered 
for several years past, as counterbalancing, m some 
measure, its numerous excellencies. 



PREFACE BY THE EDITOR. • xv 

On topics of theory, whether they relate to physi- 
ology, pathology, or therapeutics, many of its discus- 
sions are exceedingly erroneous; and its defects, with 
regard to remedies, and modes of cure, are by no means 
inconsiderable. It retains not a few of the exploded 
notions of the humoral pathology; and, although suffi- 
ciently vigorous, perhaps, in the climate of Great Bri- 
tain, where Nature seems to operate on a more limited 
scale, the treatment it recommends is, oftentimes, fee- 
ble and wholly inefficient, when opposed to the fierce 
character and rapid march of the more formidable dis- 
eases of the United States. 

Nor does the imbecility of the professor's practice, 
constitute its only, or even its greatest, imperfection. 
It is marked, in many cases, with unqualified error; a 
fault, that must necessarily have proved, in innumer- 
able instances, signally mischievous, in its influence on 
society. 

From these causes, Cullen's "First Lines" without 
notes, is a work, dangerous, in its effects, on the inex- 
perienced cultivators of medical science. Hence, the 
late declaration of a distinguished teacher, that he 
" would as soon think of placing, in the hands of a stu- 
dent of divinity, the writings of Thomas Paine, as of 
recommending, to a student of physic, Dr. Cullen's 
Practice, unaccompanied by the requisite corrections'' 

It is with a view to afford such "corrections," and 
to supply deficiencies, that our notes are annexed to 
the present edition. 

Although, from their being principally the result of 



xv i PREFACE BY THE EDITOR. 

our own experience, we might be supposed to hold 
the additions we have made in some estimation; yet, 
were that our only source of reliance, we should feel 
no small degree of diffidence, in submitting them to the 
public. But we have ample encouragement from ano- 
ther quarter. 

After a careful perusal of what we have written, the 
Professor of the Institutes and Practice of Medicine, 
in the University of Pennsylvania, whose approbation 
amounts to honourable applause, has, on account of the 
Notes, and Preliminary Discourse, adopted our edition 
of Cullen's " First Lines" as the text-book to his lec- 
tures. This speaks a language, which needs no com- 
mentary; and, which the physicians of America will 
know how to respect 

Unwilling, however, to repose exclusively on the 
sanction of high authority, we think it due, as well to 
ourselves as our readers, to remark, that, whatever im- 
perfections or faults our additions may contain, are 
not the result of either indolence or neglect. From 
the moment we engaged in the preparation of them, 
no exertions were wanting, on our part, to render them 
useful to the student, and worthy of the approbation 
of the experienced practitioner. 

Superadded to our own personal resources, in mat- 
ters of practice, we consulted the best writers, to which 
we could have access; availed ourselves of information 
from our medical correspondents: and held repeated 
conferences with some of the most distinguished phy- 
sicians of Philadelphia. From each of these sources, we 



PREFACE BY THE EDITOR. xvii 

derived advantage; but profited more abundantly by the 
free and enlightened communications from the latter. 

To have made known the names of the several gen- 
tlemen, to whom we are indebted, for practical informa- 
tion, would have afforded us pleasure: but their delicacy 
forbade the indulgence of our feelings. We can only 
beg them, therefore, to receive, each one for himself, 
the homage of our thanks. We must not, however, con- 
ceal the fact, that Dr. Chapman, with a frankness and 
liberality peculiarly his own, threw open to us several of 
his manuscript lectures, permitting us, not only to con- 
sult them, but to extract from their contents whatever 
we thought proper. Had our leisure and limits allowed 
us to avail ourselves more extensively of this privilege, 
we are sensible that our notes would have been, not a 
little, augmented in utility and value. 

There is one point, which may appear, to some, to 
require an explanation, if not an apology. 

Of the remedies recommended, we have not always 
mentioned either the doses or the modes of exhibition. 
The reason is, that the insertion of numerous formulas, 
besides giving a page an unsightly appearance, would 
have necessarily, increased the expenses of the work, 
much more than it would have increased its value. 

Every physician in the United States, ought to at- 
tend lectures on the Materia Medica; and must possess 
some work on that subject, as well as on Pharmacy. A 
Dispensatory, at least, is as necessary on his shelf, as a 
lancet is in his pocket. It is from these sources, that he 

vol. j c 



xviii PREFACE BY THE EDITOR. 

must learn the doses of medicines, as well as their pre- 
paration, and modes of exhibition. 

In our own estimation, therefore, an omission to swell 
and encumber our pages, with pharmaceutical details, 
is no fault; nor can we entertain a doubt, that, on due 
reflection, all those, whose approbation we regard, will 
concur with us in opinion. 

Philadelphia, November 1, 1816. 



PREFACE. 



JTO deliver a System of the Doctrines and Rules pro- 
per for directing the Practice of Physic, is an undertak- 
ing that appears to me to be attended with great diffi- 
culty ; and after an experience of more than forty years 
in that practice, as well as after much reading and 
reflection, it was with great diffidence that I ever enter- 
ed upon such a work. It was, however, what seemed to 
be my duty as a Professor that induced me to m^ike the 
attempt; and I was engaged in it by the same sentiments 
that the illustrious Dr. Boerhaave has expressed in the 
following passage of the preface to his Institutions : 
" Simul enim docendo admotus eram sensu, propriorum 
cogitatorum explicatione docentem plus proficere, quam 
si opus ab alio conscriptum interpretari suscipit. Sua 
quippe optime intelligit, sua cuique prae caeteris pla- 
cent, unde clarior fere doctrina, atque animata plerum- 
que sequitur oratio. Qui vero sensa alterius exponit, 
infelicius saepenumero eadem assequitur; quumque suo 
quisque sensu abundat, multa refutanda frequenter in- 
venit, unde gravem frustra laborem aggravat, minusque 
incitata dictione utitur." It is well known, that a 
Text-book is not only extremely useful, but necessary 
to Students who are to hear Lectures; and from the 
same considerations that moved Dr. Boerhaave, I also 
wished to have one for myself; while at the same time. 

VOL. I. A 



2 PREFACE. 

from some peculiar circumstances in my situation, 1 
had some additional inducements to undertake such a 
work. 

Before I was established as Professor of the Practice 
of Physic in this University, I had been employed in 
giving Clinical Lectures in the Royal Infirmary; and 
upon that occasion had delivered, what, in my own 
opinion, seemed most just with regard to both the na- 
ture and the cure of the diseases of which I had occa- 
sion to treat. But I soon found, that my doctrines 
were taken notice of^ as new, and peculiar to myself; 
and were accordingly severely criticised by those who, 
having long before been trained up in the system of 
Boerhaave, had continued to think that that system 
neither required any change, nor admitted of any amend- 
ment. I found, at the same time, that my doctrines were 
frequently criticised by persons who either had not 
been informed of them correctly, or who seemed not to 
understand them fully; and therefore, as soon as I was 
employed to teach a more complete system of the Prac- 
tice of Physic, I judged it necessary to publish a Text- 
book, not only for the benefit of my hearers, but that I 
might also have an opportunity of obtaining the opinion 
of the public more at large, and thereby be enabled 
either to vindicate my doctrines, or be taught to correct 
them. These were the motives for my attempting the 
volumes I formerly published; and now, from many 
years experience of their utility to my hearers, as well 
as from the favourable reception they have met with 
from the public, I am induced to give a new edition of 
this Work, not only, as I hope, more correct in many 
parts, but also more complete and comprehensive in its 
general extent. 

At the first publication of this work, it was intended 
chiefly for the use of those gentlemen who attended my 



PREFACE. 3 

lectures ; although even then, for the reasons I have men- 
tioned, it was rendered more full than text-books com- 
monly are; and, in the repeated editions I have since 
had occasion to give, I have been constantly endeavour- 
ing to render it more full and comprehensive. In these 
respects, I hope the present edition will appear to be 
rendered more fit for general use, and better calulated 
to afford satisfaction to all those who think they may 
still receive any instruction from reading on this subject. 

While I thus deliver my work in its now more im- 
proved state, with the hopes that it may be of use to 
others as well as to those who hear my Lectures, I must 
at the same time observe, that it presents a system 
which is in many respects new, and therefore I appre- 
hend it to be not only proper, but necessary, that I 
should explain here upon what grounds, and from what 
considerations, this has been attempted. 

In the first place, I apprehend that, in every branch 
of science with respect to which new facts are daily ac- 
quired, and these consequently giving occasion to new 
reflections, which correct the principles formerly adopt- 
ed, it is necessary, from time to time, to reform and 
renew the whole system, with all the additions and 
amendments which it has received and is then capable 
of. That at present this is requisite, with regard to the 
Science of Medicine, will, I believe, readily occur to 
every person who at all thinks for himself, and is ac- 
quainted with the Systems which have hitherto pre- 
vailed. While, therefore, I attempt this, I think it may 
be allowable, and upon this occasion even proper, that 
I should offer some remarks on the principal Systems 
of Medicine which have of late prevailed in Europe, 
and that I should take notice of the present state of 
Physic as it is influenced by these. Such remarks, I 



4 PREFACE. 

hope, may be of some use to those who attempt to im- 
prove their knowledge by the reading of books. 

Whether the practice of Physic should admit of rea- 
soning, or be entirely rested upon experience, has long 
been, and may still be, a matter of dispute. I shall not, 
however, at present, enter upon the discussion of this ; 
because I can venture to assert, that, at almost all times, 
the practice has been, and still is, with every person, 
founded more or less, upon certain principles establish- 
ed by reasoning; and therefore, in attempting to offer 
some view of the present state of Physic, I must give 
an account of those systems of the principles of science 
which have lately prevailed, or may be supposed still to 
prevail in Europe. 

When, after many ages of darkness, which had de- 
stroyed almost the whole of ancient literature, learning 
was again restored in the fifteenth century ; so from 
causes which are well known, it was the system of Ga- 
len alone that ihe Physicians of those days became ac- 
quainted with ; and during the course of the sixteenth 
century, the study of Physicians was almost solely em- 
ployed in explaining and confirming that system. Early, 
indeed, in the sixteenth century, the noted Paracelsus 
had laid the foundation of a Chemical system which 
was in direct opposition to that of Galen ; and, by the 
efficacy of the medicines employed by Paracelsus and 
his followers, their system came to be received by 
many: but the systematic Physicians continued to be 
chiefly Galenists, and kept possession of the Schools till 
the middle of the seventeenth century. It is not how- 
ever, necessary here to enter into any further detail re- 
specting the fate of those two opposite sects ; for the only 
circumstance concerning them, which I would at present 
point out, is, that in the writings of both, the explana- 
tions they severally attempted to give of the phenomena 



PREFACE. 5 

of health or sickness, turned entirely upon the state of 
the fluids of the body. 

Such was the state of the science of Physic till about 
the middle of the seventeenth century, when the circu- 
lation of the blood came to be generally known and 
admitted ; and when this, together with the discovery of 
the receptacle of the chyle, and of the thoracic duct, 
finally exploded the Galenic system. About the same 
period a considerable revolution had taken place in the 
system of Natural Philosophy. In the course of the se- 
venteenth century, Galileo had introduced mathematical 
reasoning; and Lord Bacon having proposed the me- 
thod of induction, had thereby excited a disposition to 
observe facts, and to make experiments. These new 
modes of philosophising, it might be supposed, would 
soon have had some influence on the state of medicine ; 
but the progress of this was slow. The knowledge of 
the Circulation did indeed necessarily lead to the consi- 
deration as well as to a clearer view of the Organic Sys- 
tem in animal bodies; which again led to the applica- 
tion of the mechanical philosophy towards explaining 
the phenomena of the animal economy ; and it was ap- 
plied accordingly, and continued, till very lately, to be 
the fashionable mode of reasoning on the subject. Such 
reasoning, indeed, must still in several respects continue 
to be applied : but it would be easy to show, that it nei- 
ther could, nor ever can be, applied to any great ex- 
tent in explaining the animal economy; and we must 
therefore look for other circumstances which had a 
greater share in modelling the system of Physic. 

With this view, it may be remarked, that till the pe- 
riod just now mentioned, every Physician, whether 
Galenist or Chemist, had been *o much accustomed to 
consider the state and condition of the fiukis, both as 
the cause of disease, and as the foundation for explain- 



6 PREFACE. 

ing the operation of medicines, that what we may term 
an humoral pathology still continued to make a great 
part of every system. In these circumstances, it was 
soon perceived, that chemistry promised a much better 
explanation than the Galenic or Aristotellian philoso- 
phy had done; and, therefore, while the latter was en- 
tirely laid aside, a chemical reasoning was every where 
received. Lord Bacon, with his usual sagacity, had 
early observed, that chemistry promised a great number 
of facts, and he thereby gave it credit; whilst the Cor- 
puscularian philosophy, restored by Gassendi, readily 
united with the reasonings of the Chemists ; and the 
Philosophy of Des Cartes readily united with both. 
From all these circumstances, an Humoral, and chiefly 
a Chemical Pathology, came to prevail very much till 
the end of the last century; and has, indeed, continued 
to have a great share in our systems down to the pre- 
sent time. 

It is proper now, however, to observe, that about the 
beginning of the present century, when every part of 
science came to be on a more improved and correct 
footing, there appeared in the writings of Stahl, of 
Hoffman, and of Boerhaave, three new^ and con- 
siderably different, Systems of Physic; which have ever 
since had a great share in directing the practice of it. 
In order, therefore, to give a nearer view of the present 
state of Physic, I shall offer some remarks upon these 
different systems; endeavouring to point out the advan- 
tages, as well as the disadvantages of each, and how far 
they still prevail ; or, according to my judgment, deserve 
to do so. 

I shall begin with considering that of Dr. Stahl, 
which I think appeared first, and for a long time after 
was the prevailing system in Germany. 

The chief and leading principle of this system is, that 



PREFACE. 7 

the rational soul of man governs the whole economy of 
his body. At all times, Physicians have observed that 
the animal economy has in itself a power or condition, 
by which, in many instances, it resists the injuries 
which threaten it; and by which it also, on many occa- 
sions, corrects or removes the disorders induced, or 
arising in it. This power, Physicians very anciently 
attributed, under a vague idea, to an agent in the sys- 
tem, which they called nature; and the language of a 
vis conservatrix et medicatrix natures, has continued in 
the schools of medicine from the most ancient times to 
the present. 

Dr. Stahl has explicitly founded his system on the 
supposition that the power of nature, so much talked 
of, is entirely in the rational soul. He supposes, that 
upon many occasions, the soul acts independently of 
the state of the body; and that, without any physical 
necessity arising from that state, the soul, purely in 
consequence of its intelligence perceiving the tendency 
of noxious powers threatening, or of disorders any wise 
arising in the system, immediately excites such motions 
in the body as are suited to obviate the hurtful or per- 
nicious consequences which might otherwise take place. 
Many of my readers may think it was hardly necessary 
for me to take notice of a system founded upon so fan- 
ciful an hypothesis; but there is often so much seeming 
appearance of intelligence and design in the operations 
of the animal economy, that many eminent persons, as 
Perrault in France, Nichols and Mead in England, 
Porterfald and Simson in Scotland, and Gaubius in 
Holland, have very much countenanced the same opi- 
nion, and it is therefore certainly entitled to some regard. 
It is not, however, necessary for me here to enter into 
any refutation of it. Dr. Hoffman has done this fully, 
in his Commentarius de differentia inter Hqffmanni doc- 



8 PREFACE. 

trinam medico-mechanicam et G. E. Stahlii medicQ-or- 
ganicam; and both Boerhaave and Haller, though no 
favourers of materialism, have mentioned a doctrine very 
opposite to that of Stahl. 

In my Physiology I have offered some arguments 
against the same; and I shall only add now, that who- 
ever considers what has been said by Dr. Nichols in his 
Oratiode AmmaMedica, and by Dr. Gaubius in some 
some parts of his Pathology, must perceive, that the 
admitting of such a capricious government of the ani- 
mal economy, as these authors in some instances sup- 
pose, would at once lead us to reject all the physical 
and mechanical reasoning we might employ concerning 
the human body. Dr. Stahl himself seems to have been 
aware of this; and therefore in his preface to Juncker's 
Conspectus Therapeia Specialis, has acknowledged, that 
his general principle was not at all necessary; which 
is in effect saying that it is not compatible with any 
system of principles that ought to govern our practice. 
Upon this footing, I might have at once rejected the 
Stahlian principle: but it is even dangerous to bring any 
such principle into view; for, after all Dr. Stahl had 
said in a passage just now referred to, I find, that, in the 
whole of their practice, both he and his followers have 
been very much governed by their general principle. 
Trusting much to the constant attention and wisdom of 
nature, they have proposed the Art of curing by expec- 
tation; have therefore, for the most part, proposed only 
very inert and frivolous remedies; have zealously op- 
posed the use of some of the most efficacious, such as 
opium and the Peruvian bark; and are extremely re- 
served in the use of general remedies, such as bleeding, 
vomiting, &c. 

Although these remarks, upon a system which may 
now be considered as exploded or neglected, may seem 



PREFACE. 9 

superfluous; I have been willing to give these strictures 
on the Stahlian system, that I might carry my remarks 
a little farther, and take this opportunity of observing, 
that, in whatever manner we may explain what have 
been called the operations of nature, it appears to me, 
that the general doctrine of Nature curing diseases, the 
so much vaunted Hippocratic method of curing, has 
often had a baneful influence on the practice of physic; 
as either leading physicians into, or continuing them in, 
a weak and feeble practice; and at the same time su- 
perseding or discouraging all the attempts of art. Dr. 
Huxham has properly observed that even in the hands 
of Sydenham it had this effect. Although it may some- 
times avoid the mischiefs of bold and rash practitioners, 
yet it certainly produces that caution and timidity which 
have ever opposed the introduction of new and effica- 
cious remedies. The opposition to chemical medicines 
in the sixteenth and seventeenth centuries, and the 
noted condemnation of Antimony by the Medical Fa- 
culty of Paris, are to be attributed chiefly to those pre- 
judices, which the physicians of France did not entirely 
get the better of for near an hundred years after. We 
may take notice of the reserve it produced in Boer- 
haave, with respect to the use of the Peruvian bark. 
We have had lately published, under the title Consti- 
tutiones Epidemical, notes of the particular practice of 
the late Baron Van Swieten : upon which the editor 
very properly observes, That the use of the bark, in in- 
termitting fevers, appears very rarely in that practice; 
and we know very well where Van Swieten learned that 
reserve. 

I might go farther, and show how much the attention 
to the jlutocrateia, allowed of, in one shape or other, 
by every sect, has corrupted the practice among all 
physicians, from Hippocrates to Stahl. It must, how- 

VOL. I. B 



10 PREFACE. 

ever, be sufficiently obvious, and I sboll conclude the 
subject with observing, that although this vis medica- 
trix natures, must unavoidably be received as a fact; 
yet wherever it is admitted, it throws an obscurity upon 
our system; and it is only where the impotence of our 
art is very manifest and considerable, that we ought to 
admit of it in practice. 

To finish our remarks upon the Stahlian system, I 
shall shortly observe, that it did not depend entirely 
upon the Avtocraleia, but also supposed a state of the 
body and diseases, that admitted of remedies, which, 
under the power and direction of the soul, acted upon 
the organization and matter of the body, so as to cure 
its diseases. Upon this footing, the Stahlian pathology 
turned entirely upon Plethora and Cacochymy. It was 
with respect to the former that they especially applied 
their doctrine of the Jiutocrateia in a very fantastical 
manner; and, with respect to the latter, they have been 
involved in a humoral pathology as much as the syste- 
matic physicians who had gone before them, and with 
a theory so incorrect as not to merit the smallest atten- 
tion. After all, I ought not to dismiss the consideration 
of the Stahlian system, without remarking, that as the 
followers of this system were very intent upon observ- 
ing the method of nature, so they were very attentive in 
observing the phenomena of diseases, and have given 
us in their writings many facts not to be found else- 
where. 

While the doctrines of Stahl were prevailing in the 
university of Halle, Dr. Hoffman, a professor in the 
same university, proposed a system that was very dif- 
ferent. He received into his system a great deal of the 
mechanical, Cartesian, and chemical doctrines of the 
systems which had appeared before: but with respect to 
these, it is of no consequence to observe in what man- 



PREFACE. 11 

ner he modified the doctrines of his predecessors, as his 
improvements in these respects were no ways consider- 
able, and no part of them now remain; and the real 
value of his works, beyond what I am just now going 
to mention, rests entirely on the many facts they con- 
tain. The merit of Dr. Hoffman and of his works is, 
that he made, or rather suggested, an addition to the 
system, which highly deserves pur attention. Of this I 
cannot give a clearer account than by giving it in the 
author's own words. In his Medicina Rationalis Sys- 
tematica, Tom. III. § 1. chap. iv. he has given his 
Genealogia morborum ex turbato solidorum et Jluido- 
rum mechanismo; and in the 47th and last paragraph 
of this chapter he sums up his doctrine in the following 
words: ' c Ex hisce auteni omnibus uberius hactenus 
excussis, per quam dilucide apparere arbitror, quod so- 
lus spasmus et simplex atoma, aequabilem, liberum, ac 
proportionatum sanguinis omnisque generis fluidorum 
motum, quibus excretionum successus et integritas 
functionum animi et corporis proxime nititur, turbando 
ac pervertendo, universam vitalem oeconomiam subru- 
ant ac destruant; atque hinc universa pathologia longe 
rectius atque facilius ex vitio motuum microcosmico- 
rum in solidis, quam ex varus affectionibus vitio- 
sorum humorum, deduci atque explicari possit, adeo- 
que omnis generis aegritudines internae, ad pr^ter>a- 
turale> generis nervosi affectiones sint referendae. 
Etenim laesis quocunque modo, vel nervis per corpus 
discurrentibus, vel membranosis quibusvis nervosis par- 
ibus, illico motuum anomaliae, modo lev iores, modo gra- 
viores subsequuntur. Deinde attenta observatio docet, 
motus quosvis morbosos principaliter sedem Agere et 
tyrannidem exercere in nervosis corporis partibus, cujus 
generis proeter omnes canales, qui systaltico et diastal- 
tico motu pollentes, contentos succos tradunt, univer- 



12 PREFACE. 

sum nimirum intestinorum et ventriculi ab oesopbago 
ad anum canalem, totum systema vasorurn artenoso- 
rum, ductuum biliariorum, salivalium, urinarioruni et 
subcutaneorum, sunt quoque mcmbranae nerveo-mus- 
culares cerebri et medullas spinalis, praesertim ha3c, qu;v 
dura mater vocatur, organis sensoriis obductae, nee nen 
tunicas illae ac ligamenta, qua; ossa cingunt artusque 
firmant. Nam nullus dolor, nulla inflammatio, nulltts 
spasmus, nulla motus et sensus impotenlia, nulla febrifi 
humoris illius excretio, accidit, in qua non has partes 
patiantur. Porro etiam omnes, quae morbos gignunt 
causae, operationem suam potissiniam perficiunt in par- 
tes motu et sensu prasditas, et canales ex his coagmen- 
tatos, eorum motum, et cum hoc fluidorum cursum, 
perventendo ; ita tamen, ut sicuti variae indolis sunt, sic 
etiam varie in nerveas partes agant, iisdemque noxam 
affiricent. Demum omnia quoque eximiae virtutis medi- 
camenta, non tarn in partes fluidas, earum crasin ac in- 
temperiem corrigendo, quam potius in solidas et nervo- 
sas, earundem motus alterando ac moderando, suam 
edunt operationem: De quibus tamen omnibus, in vul- 
gari usque eo recepta morborum doctrina, altum est si- 
lent ium." 

It is true, that Dr. Willis had laid a foundation for 
this doctrine, in his Pathologia Cerebri et Nervorum; 
and Baglivi had proposed a system of this kind in his 
Specimen de fibra motrici et morbosa. But in these wri- 
ters it was either not extensively applied to diseases, or 
was still so involved in many physiological errors, that 
they had attracted little attention ; and Dr. Hoffman was 
the first who gave any tolerable simple and clear system 
on the subject, or pointed out any extensive application 
of it to the explanation of diseases. 

There can be no sort of doubt that the phenomena of 
the animal economy in health and in sickness, can only 



PREFACE. 13 

be explained by considering the state and affections of 
the primary moving powers in it. It is to me surprising 
that physicians were so long in perceiving this, and I 
think we are particularly indebted to Dr. Hoifman for 
putting us into the proper train of investigation; and it 
every day appears that physicians perceive the neces- 
sity of entering more and more into this inquiry. It was 
this. I think, which engaged Dr. Kaaw Boerhaave to 
publish his work entitled Impctumjacieiis; as well as 
Dr. Gatibius to give the Pathology of the Solidum vi- 
vum. Even the Baron Van Swieten has upon the 
same view thought it necessary, in at least one particu- 
lar, to make a very considerable change in the doctrine 
of his master, as he has done in his Commentary upon 
the 775th Aphorism. Dr. Haller has advanced this 
part of science very much by his experiments on irrita- 
bility and sensibility. In these and in many other in- 
stances, particularly in the writings of Mr. Barthez of 
Montpelier, of some progress in the study of the affec- 
tions in the Nervous System, we must perceive how 
much we are indebted to Dr. Hoffman for his so pro- 
perly beginning it. The subject, however, is difficult: 
the laws of the Nervous System, in the various circum- 
stances of the animal economy, are by no means ascer- 
tained; and from want of attention and observation with' 
the view to a system on this subject, the business appears 
to many as an inexplicable mystery. There is no won- 
der therefore, that on such a difficult subject, Dr. Hoff- 
man's system was imperfect and incorrect; and has had 
less influence on the writings and practice of physicians 
since his time, than might have been expected. He 
himself has not applied his fundamental doctrine so ex- 
tensively as he might have done; and he has every 
where intermixed a Humoral Pathology, as incorrect 
and hypothetical as any other. Though he differed 



U PREFACE. 

from his colleague Dr. Stahl in the fundamental doc- 
trines of his system, it is but too evident that he was 
very much infected with the Stahlian doctrines of Ple- 
thora and Cacochymy, as may be observed throughout 
the whole course of his work; and particularly in his 
chapter Da morborum generations ex nimia sanguinis 
qunnlitate el humorum impuritate. 

But it is needless for me to dwell any longer upon the 
system of Hoffman; and I am next to offer some re- 
marks on the system of Dr. Boerhaave, the contempo- 
rary of. both the other Systematics, and who, over all 
Europe, and especially in this part of the world, gained 
higher reputation than either of the others. 

Dr. Boerhaave was a man of general erudition; and, 
in applying to medicine, he had carefully studied the 
auxiliary branches of Anatomy, Chemistry, and Botany, 
so that he excelled in each. In forming a system of 
Physic, he seems to have studied diligently all the se- 
veral writings of both ancient and modern Physicians; 
and, without prejudice in favour of any former systems, 
he endeavoured to be a candid and genuine eclectic. 
Possessed of an excellent systematic genius, he gave a 
system superior to any that ever before appeared. As in 
the great extent, and seemingly perfect consistency, of 
system, he appeared to improve and refine upon every 
thing that had before been offered; and as in his Lec- 
tures he explained his doctrines with great clearness and 
elegance, he soon acquired a very high reputation, and 
his system was more generally received than any for- 
mer had been since the time of Galen. Whoever will 
consider the merits of Dr. Boerhaave, and compare his 
system with that of former writers, must acknowledge 
that he was very justly esteemed, and gave a system 
which was at that time deservedly valued. 

But, in the progress of an inquisitive and industrious 



PREFACE. ]5 

age, it was not to be expected that any system should 
last so long as Boerhaave's has done. The elaborate 
Commentary of Van Svvieten on Boerhaave's system of 
practice, has been only finished a few years ago; and 
though this Commentator has added many facts, and 
made some corrections, he has not, except in the parti- 
cular mentioned above, made any improvement in the 
general system. It is even surprising that Boerhaave 
himself, though he lived near forty years after he had 
first formed his system, had hardly in all that time made 
any corrections of it or additions to it; the following is 
the most remarkable. In Aphorism 755, the words 
forte et nervosi, tarn cerebri quam cerebelli cordi destinaii 
inertia, did not appear in any edition before the fourth; 
and what a difference of system this points at, every 
physician must perceive. 

When I first applied to the study of Physic, I learned 
only the system of Boerhaave; and even when I came to 
take a Professor's chair in this university, I found that 
system here in its full force; and as I believe it still sub- 
sists in credit elsewhere, and that no other system of 
reputation had been offered to the world, I think it ne- 
cessary for me to point out particularly the imperfec- 
tions and deficiencies of the Boerhaavian system, in or- 
der to show the propriety and necessity of attempting a 
new one. 

To execute this, however, so fully as I might, would 
lead me into a detail that can hardly be admitted of here; 
and I hope it is not necessary, as I think, that every in- 
telligent person, who has acquired any tolerable know- 
ledge of the present state of our science, must in many 
instances perceive its imperfections. I shall therefore 
touch only upon the great lines of this system; and from 
the remarks I am to offer, trust that both the mistakes 



lt> PREFACE. 

and deficiencies which run through the whole of his 
works will appear. 

Dr. Boerhaave's treatise of the diseases of the simple 
solid, has the appearance of b< ing very clear and consis- 
tent, and was certainly considered by him as a funda- 
mental doctrine; but, in my apprehension, it is neither 
correct nor extensively applicable, not to mention the 
us less, and perhaps erroneous, notion of the composi- 
tion of earth and gluten; nor his mistake concerning the 
structure of compound membranes; nor his inattention 
to the state of the cellular texture; all of them circum- 
stances which render his doctrine imperfect; I shall in- 
sist only upon the whole being very little applicable to 
the explaining the phenomena of health or sickness. 
The laxity or rigidity of the simple solid, does, indeed, 
take place at the different periods of life, and may per- 
haps, upon other occasions, occur as the cause of dis- 
ease; but I presume, that the state of the simple solid 
is, upon few occasions, either changeable or actually 
changed; and that in ninety-nine cases of an hundred, 
the phenomena attributed to such a change, do truly 
depend on the state of the solidum vivum; a circum- 
stance which Dr. Boerhaave has hardly taken notice of 
in any part of his works. How much this shows the 
deficiency and imperfection of his system, I need not 
explain. The learned work of Dr. Gaubius, above re- 
ferred to, as well as many other treatises of late authors, 
point out sufficiently the defects and imperfections of 
Boerhaave on this subject. 

After Dr. Boerhaave has considered the diseases of 
the solids, he in the next place attempts to explain the 
more simple diseases of the fluids; and there indeed he 
delivers a more correct doctrine of acid and alkali than 
had been given before: but, after all, he has done it very 
imperfectly. We have, indeed, since his time, acquired 



PREFACE. j7 

more knowledge upon the subject of digestion ; and so 
much as to know, -that a great deal more is yet neces- 
sary to enable us to understand in what manner the ani- 
mal fluids are formed from the aliments taken in. And 
although Dr. Boerhaave has fallen into no considerable 
error with respect to a morbid acidity in the stomadh, 
he could not possibly be complete upon that subject; 
and his notion of the effects of acidity in the mass of 
blood, seems to have been entirely mistaken, and is, in- 
deed, not consistent with what he himself has delivered 
elsewhere. 

His doctrine of alkali is somewhat better founded, but 
is probably carried too far; and the state of alkales- 
cency and putrefaction, as well as all the other changes 
which can take place in the condition of animal fluids, 
are particulars yet involved in great obscurity, and are 
therefore still subjects of dispute. 

There is another particular, in which Boerhaave's 
doctrine concerning the fluids appears to me imperfect 
and unsatisfactory; and that is, in his doctrine de Glu- 
tinnso spontanea. The causes which he has assigned 
for it are by no means probable, and the actual existence 
of it is seldom to be proved. Some of the proofs ad- 
duced for the existence of a phle*jma calidum, are mani- 
festly founded upon a mistake with respect to what has 
been called the inflammatory crust, (See Van Swieten's 
Commentary, page 9G ); and the many examples given 
by Boerhaave of a glutinosum appearing in the human 
body, (Aph. 75.) are all of them nothing more than in- 
stances of collections or concretions found out of the 
course of the circulation. 

If, then, we consider the imperfections of Dr. Boer- 
haave's doctrine with respect to the state and various 
condition of the animal fluids; and if at the same time 
we r fleet how frequently he and his followers have em- 
vol. i. e 



18 PREFACE. 

ployed the supposition of an acrimony or lentor of the^ 
fluids, as causes of disease, and for directing the prac-' 
tice; we must, as I apprehend, be satisfied, that his sys- 
tem is not only deficient and incomplete, but fallacious 
and apt to mislead. Although it cannot be denied, that 
the fluids of the human body suffer various morbid 
changes; and that upon these diseases may primarily 
depend; yet I must beg leave to maintain, that the na- 
ture of these changes is seldom understood, and more, 
seldom still is it known when they have taken place: 
that our reasonings concerning them have been, for the 
most part, purely hypothetical; have therefore contri- 
buted nothing to improve, and have often misled, the 
practice of physic. In this, particularly, they have been 
hurtful, that they have withdrawn our attention from, 
and prevented our study of, the motions of the animal 
system, upon the state of which the phenomena of dis- 
eases do more certainly and generally depend. Who- 
ever, then, shall consider the almost total neglect of the 
state of the moving powers of the animal body, and the 
prevalence of an hypothetical humoral pathology, so 
conspicuous in every part of the Boerhaavian system, 
must be convinced of its very great defects, and per- 
ceive the necessity of attempting one more correct. 

After giving this general view, it is not requisite to 
enter into particulars; but, I believe, there are very lew 
pages of his aphorisms in which there does not occur 
some error or defect; although, perhaps, not to be 
imp :ted to the fault of Boerhaave, so much as to this 
that since his time a great collection of new facts has 
been acquired by observation and experiment. This 
indeed, affords the best and most solid reason for at- 
tempting a new system: for when many new facts have 
been acquired, it becomes requisite that these should 
be incorporated into a system, whereby not only parti- 



PPEFACE. 19 

cular subjects may be improved, but the whole may be 
rendered more complete consistent, and useful. Every 
system, indeed, must be valued in proportion to the 
number of facts that it embraces and comprehends; and 
Mons. Quesney could not pay a higher compliment to 
the system of Boerhaave, than by sayii.g that it exhi- 
bited La medicine collective 

But here it will, perhaps, be suggested to me, that 
the only useful work on the subject of physic, is the mak- 
ing a collection of all the facts that relate to the art, 
and therefore of all that experience has taught us with 
respect to the cure of diseases. I agree entirely in the 
opinion; but doubt if it can ever be properly accom- 
plished, without aiming at some system of principles, 
by a proper induction and generalization of facts: at 
least I am persuaded that it can be done not only very 
safely, but most usefully in this way. This, however, 
must be determined by a trial. 1 know that the late Mr. 
Lieutaud has attempted a work on the plan of collect- 
ing facts, without any reasoning concerning their causes: 
And while I am endeavouring to give some account of 
the present state of physic, I cannot dismiss the subject 
without offering some remarks upon the promising Sy- 
nopsis universal medicince, composed by the first physi- 
cian of a learned and ingenious nation. 

In this work there are many facts and much observa- 
tion from the author's own experience, which may be 
useful to those who have otherwise some knowledge and 
discernment; but, throughout the whole work, there is 
such total want of method, arrangement system, or de- 
cision, that, in my humble opinion, it can be of little use, 
and may prove very perplexing to those who are yet to 
learn. The distinction of the genera of diseases, the 
distinction of the species of each, and often even that of 
the varieties, I hold to be a necessary foundation of 



20 PREFACE. 

every plan of physic, whether dogmatical or empirical. 
But very little of this distinction is to be found in the 
work of Mr. Lieutaud ; and in his preface he tells us, that 

he meant to neglect such arinita sedulitas. And indeed 

• i ■ 
his method of managing his subject must certainly in- 
terrupt and retard all methodical nosology. His arrange- 
ment of diseases is according to no affinity, but that of 
the slightest and uninstructivc kind, the place of the 
body which they happen to affect. His Generalia el 
incertce sedis, have hardly any connexion at all; the 
titles Rheumatisms, Hypochondriasis, Hydrops, follow 
one another. When he does attempt any general doc- 
trine, it is not till long after he has treated of the widely 
scattered particulars. Under each particular title 
which he assumes, he has endeavoured to enumerate the 
whole of the symptoms that ever appeared in a disease 
under that title; and this without aiming at any distinc- 
tion between the essential and accidental symptoms, or 
marking the several combinations under which these 
symptoms do for the most part steadily appear. From 
the concurrence of accidental symptoms, the variety of 
the same disease is frequently considerable, a circum- 
stance necessarily perplexing and distracting to young 
practitioners; but it seems strange to me, that an expe- 
rience of thirty years, in considerable practice, could do 
nothing to relieve them. 

Mr. Lieutaud has at the same time increased the con- 
fusion that must arise from this want of distinction, by 
his considering as primary diseases, what appear to me 
to be the symptoms, effects, and sequels, of other dis- 
eases only. Of this I think, the JEstus morbosus, Virum 
cxolutio, Dolores, Stagnatio sanguinis, Pwulentia, Tre- 
mor, Pervigilium, Raucedo, Suffocatio, Vomica, Em- 
pyema, Singultus, Vomitus, Dolor Sfcmachi, Tenes- 
mus, all treated of under separate titles, are examples. 



PREFACE. 21 

A general symptomatologia may be a very useful work, 
with a view to a system of Pathology; but with a view 
to practice without any System, it must have bad effects, 
as leading only to a palliative practice, and diverting 
from the proper efforts towards obtaining a radical cure. 
Mr. Lieutaud, indeed, has endeavoured to exhibit the 
symptoms above mentioned as so many primary dis- 
eases: but he has seldom succeeded in this; and, in 
delivering the practice, he commonly finds it necessary 
to consider them as symptoms, and that not without 
some theory, implied or expressed, with respect to their 
proximate causes. His title of Dolores may be taken 
as an example of this; and from which it may be rea- 
dily perceived how far such treatises can be really 
useful. 

In establishing a proper pathology, there is nothing 
that has been of more service than the dissection of 
morbid bodies. Mr. Lieutaud has been much and most 
eommendably employed in this way, and in this Sy- 
nopsis he has endeavoured to communicate his know- 
ledge on the subject; but in my humble opinion, he has 
seldom done it in a manner that can be useful. In the 
same way that he has delivered the symptoms of dis- 
eases without any instructive arrangement; so on the 
subject of the appearances after death, he has mentioned 
every morbid appearance that had ever been observed 
after the disease of which he is then treating; but these 
appearances are strangely huddled together, without 
any notice taken of those which belong to one set of 
symptoms or to another; and with regard to the whole, 
without any attempt to distinguish between the causes 
of diseases and the causes of death; although the want 
of such distinction is the well known ground of fallacy 
upon this subject. I take for an example, the ap- 
pearances mentioned as having been observed after 



22 PREFACE. 

dropsy. Here morbid appearances, found in every part 
of (he body, in every cavity of it, and in every viscus 
contained in these cavities, are enumerated: but which 
of these morbid states are more frequent or more rare, 
and which has been more particularly connected with 
the different causes or with the different state of symp- 
toms previously recited, wc are not informed, nor has 
he enabled us to discover. In short, the dissection of 
morbid bodies has been, and may be, highly useful ; but, 
in order to be so, it must be under a different manage- 
ment from what we find either in this Synopsis, or even 
in the Historia Anatomico-medica. 

I cannot dismiss this subject without remarking, that 
the dissection of morbid bodies, is chiefly valuable upon 
account of its leading us to discover the proximate 
causes of diseases; and the great and valuable work of 
the illustrious Morgagni is properly intitled De sedibus 
et causis. It may well seem surprising, then, that 
Lieutaud should find the whole of proximate causes 
atra caligine mersas; and that he should never have 
thought of applying his dissections towards the ascer- 
taining at least some of these. 

But let me now proceed to consider the important 
part of every practical work, and of this Synopsis uni- 
versal medicince: that is, the method of curing diseases. 

Here, again, upon the same plan as in giving the 
histories of disease, the method of cure is delivered by 
enumerating the whole of the remedies that have ever 
been employed in a disease under the title prefixed- 
without assigning the species, or the circumstances to 
which the remedies, though of a very different and 
sometimes opposite nature, are particularly adapted. On 
the subject of Asthma, he very justly observes that phy- 
sicians have been to blame in confounding, under this 
title, almost all the species of Dyspnoea; and he himself 



PREFACE. 23 

very properly considers Asthma as a disease distinct 
from all the other cases of Dyspnoea. Still, however, he 
considers Asthma as of many different species, arising 
from many different causes, which till we understand 
better, we cannot attempt to remove. Notwithstanding 
all this, he proceeds to deliver a very general cure. 
Parum abest, says he, quia specifici titulo gaudeant pec- 
tor alia, vulneraria, et incidentia! But from such lan- 
guage I receive no clear idea; nor can I obtain any 
clear direction from the enumeration of his medicines. 
Baccce juniperi, gummi, tragacanthum vel ammonia- 
cum, sapo aqua picea, terebinthina, fyc. quae tamen 
haud indiscriminatim sunt usurpanda, sed pro re nata, 
dcluctu opus est Very justly, indeed, deluctu opus est; 
but here, as in many others instances, he gives us no 
sort of assistance. 

From his endeavours, though not always successful, 
to neglect all system, his practice is generally delivered 
in a very indecisive manner; or, what has the same 
effect, in a way so conditional as will render it always 
difficult, and often impossible, for a young practitioner 
to follow him. Let us take, for example, his cure of 
Dropsy. " The cure may be begun by blood-letting in 
certain conditions; but in others, it cannot be employed 
ivithout danger. It gives relief in difficult breathing; 
but, after it is practised, the symptoms are aggravated, 
and rendered more obstinate. It is not to be concealed 
that some persons have been cured by repeated blood- 
lettings, or spontaneous haemorrhagies; but it is at the 
same time known, that such a remedy inopportunely 
employed, has in many instances hastened on the fatal 
event." 

In the same manner, he treats of vomiting, purging, 
sweating, and the use of mineral waters; but I must 
confess, that he has no where removed any of my 



24 PREFACE. 

doubts or difficulties, and indeed he has sometimes in- 
creased them. He says, that hepatics, or aperients, such 
as the lingua cervina, herbce capillares, fyc. deserve com- 
mendation; but that when the disease has arisen to a 
certain degree, they have been, for tke most part, found 
to be useless. He observes, that the powder of toads 
given in wine, to the quantity of a scruple or more, has 
succeeded with severals. 

Such are commonly the methods of cure delivered 
by Mr. Lieutaud, longiori et forte felicissima praxi 
edoctus. 

It would be tedious to enter further into that detail, 
which a criticism of this immethodical and uninstruc- 
tive work might lead me into; but, if the bounds pro- 
per for this preface did not prevent mc, I would parti- 
cularly show that the work is far from being free from 
those reasonings which the author pretends to avoid, 
and would affect even to despise. He still holds the 
doctrines of the concoction and critical evacua- 
tion of morbific matter; doctrines depending upon 
subtile theories, and which, in my opinion, can in no 
wise be ascertained as matters of fact. Mr. Lieutaud 
likewise is still very much upon the old plan of follow- 
ing nature, and therefore gives often what I consider 
as a feeble and inert practice. The hamectantia, dilu- 
entia* demidccntia, et tcmperantia, are with him very 
universal remedies, and often those which alone are to 
be employed. 

The mention of these medicines might lead mo to 
take notice of Mr. Lieutauds second volume, in which, 
ab insula remediorum farragive alienus, he promises a 
great reformation upon the subject; but this fails so far 
short of the idea of British physicians, that I need not 
make any remarks upon it. With respect to his list of 
simples, or Emporetica, as he is pleased to term them. 



PREFACE. 25 

an English apothecary would smile at it; and with re- 
spect to his Officinalia, I believe they are to be found 
no where but in the Codex Medicamentarias of Paris; 
and in his Magistralia his doses are generally such as 
the most timid practitioner of this country would hardly 
descend to; and such as none of our practitioners of 
experience would depend upon. In short, the whole 
of the work, both with respect to the theories with 
which it abounds, and to the facts which it gives, will 
not, in my apprehension, bear any serious criticism. 
But I must conclude; and shall only say further, that 
such as I have represented it, is this work, executed 
by a man of the first rank in the profession. It is in- 
deed for that reason I have chosen it as the example 
of a work, upon the plan of giving facts only, and of 
avoiding the study, or even the notice of the proximate 
causes of diseases; and with what advantage such a 
plan is pursued, I shall leave my readers to consider. 

In the following treatise I have followed a different 
course. I have endeavoured to collect the facts relative 
to the diseases of the human body, as fully as the nature 
of the work and the bounds necessarily prescribed to it 
would admit; but I have not been satisfied with giving 
the facts, without endeavouring to apply them to the 
investigation of proximate causes, and upon these to 
establish a more scientific and decided measure of cure. 
In aiming at this, I flatter myself that I have avoided 
hypothesis, and what have been called theories. I have, 
indeed, endeavoured to establish my general doctrines", 
both physiological and pathological ; but I trust that 
these are only a generalization of facts, or conclusions 
from a cautious and full induction ; and if any one shall 
refuse to admit, or directly shall oppose, my general 
doctrines, he must do it, by showing that I have been 
deficient or mistaken in assuming and applying facts. I 

vol. i. T) 



26 PREFACE. 

have, myself, been jealous of my being sometimes im- 
perfect in these respects; but I have generally endea- 
voured to obviate the consequence of this, by proving, 
that the proximate causes which I have assigned, are 
true in fact, as well as deductions from any reasoning 
that I may seem to have employed. Further, to obviate 
any dangerous fallacy in proposing a method of cure, I 
have always been anxious to suggest that which, to the 
best of my judgment, appeared to be the method ap- 
proved of by experience, as much as it was the conse- 
quence of system. 

Upon this general plan I have endeavoured to form a 
system of physic that should comprehend the whole of 
the facts relating to the science, and that will, I hope, 
collect and arrange them in better order than has been 
done before, as well as point out in particular those 
which are still wanting to establish general principles. 
This which I have attempted may, like other systems, 
hereafter suffer a change; but I am confident that we 
are at present in a better train of investigation than phy- 
sicians were in before the time of Dr. Hoffman. The 
affections of the motions and moving powers of the ani- 
mal economy, must certainly be the leading inquiry in 
considering the diseases of the. human body. The in- 
quiry may be difficult; but it must be attempted, or the 
subject must be deserted altogether. I have therefore 
assumed the general principles of Hoffman, as laid down 
in the passage which I have quoted above ; and if I have 
rendered them more correct, and more extensive in 
their application ; and more particularly, if I have avoid- 
ed introducing the many hypothetical doctrines of the 
Humoral Pathology which disfigured both his and all 
the other systems which have hitherto prevailed; I hope 
I shall be excused for attempting a system, which upon 
the whole may appear new. 
Edinburgh, Nov. 1789. 



PRELIMINARY DISCOURSE, 

BY THE EDITOR. 



WERE it not for the measures of unrelenting hosti- 
lity prosecuted for years, by a late distinguished teacher 
in the University of Pennsylvania, for the overthrow of 
systematic and classical medicine, we could have no 
plea for wishing to occupy any portion of the time of 
our readers in attempting its defence. For more than a 
century preceding the commencement of this war of 
extermination, thus openly and formally declared 
against it, Methodical Nosology had been considered as 
resting on the immoveable basis of reason, experience, 
and the unqualified approbation of every enlightened 
physician of the time. It had been regarded as a 
branch of medicine originating in necessity, sanctioned 
by utility, and founded in the immutable nature of dis- 
ease. But ingenuity and sophistry may become dan- 
gerous weapons in any department of practical science. 
When employed by ambition, and wielded by a daring 
spirit of innovation, they are capable of spreading dark- 
ness, for a season, around the brightest truths, and giv- 
ing a temporary lustre to the wildest hypotheses. 

When we recollect the high and imposing rank of 
the professor to whom we have just alluded, and add to 
this, the formidable power and extent of his means, 
against such opinions as he wished to destroy — placed, 



28 PRELIMINARY DISCOURSE. 

as a practitioner, at the head of his profession, acute 
and ingenious as a writer, eloquent and unusually 
popular as a teacher, zealous and indefatigable in his 
favourite pursuits, and possessing, through the medium 
of his lectures and writings, opportunities peculiar to 
himself for ensuring a wide dissemination of his doc- 
trines — when we call to mind these considerations, and 
subjoin what our own observation has taught us, we 
can no longer doubt, that, in relation to the truth and 
usefulness of systematic nosology, the belief of hun- 
dreds has been seriously shaken — that dangerous he- 
resies have been abundantly infused into the minds of 
many of the physicians of the United States, and that, 
on practical no less than scientific grounds, the interest 
of medicine calls for their removal. Such are the evils 
which, in professional science, can scarcely fail to re- 
sult from the labours of distinguished individuals who 
unfortunately mistake alteration for improvement, and 
innovation for reform. 

To aid, to the extent of our humble means, in the 
eradication of those errors, which have thus been im- 
planted in a portion of the medical mind of our country, 
and in the restoration of certain rejected doctrines, of 
the soundness of which we have not ceased to be per- 
suaded, and the cause of which we have never abandon- 
ed, constitutes the principal object of this discourse. 
To render it as conclusive as possible, and to bestow 
on it somewhat of an elementary and didactic charac- 
ter, we shall attempt, in the course of it, an analytical 
view of the grounds and principles of classical arrange- 
ment. 

The true basis of system and classification in science 
is, affinity in some points, and dissimilarity in others; 
their object and tendency, to facilitate the acquisition 
of knowledge, by compressing what is scattered, sim- 



PRELIMINARY DISCOURSE. 29 

plifying and rendering clear what is dark and intricate, 
and reducing to order what is irregular and confused. 
Such are their effects in Natural History at large, and 
its subordinate branches. Zoology and Botany, Geology 
and Mineralogy; and such are also the aids they afford 
in the study of Metaphysics and Chemistry, Philology 
and Moral Science; such, in fact, are the helps and faci- 
lities which they alone can bestow on those who are in 
pursuit of general knowledge. 

Without the advantages of systematic arrangement, 
every field of research, whether natural or moral, meta- 
physical or literary, would remain in the condition of 
an uncultivated waste, marked by the footsteps of dis- 
order and barrenness. The sunshine of real science 
could never quicken it, nor could the hand of industry 
render it fruitful. The adventurous explorer might in- 
deed pass through it, and be, in no small degree, de- 
lighted with the novelties around him: he might even, 
for a time, fancy himself instructed; but every thing 
being blended without regularity or order, nothing 
would present itself to him in its true relations: hence, 
his recollection of all he had seen being indistinct and 
confused, his labours would be unprofitable to those 
who might follow him. He could leave behind him 
scarcely a track or a beacon for the direction of their 
course. 

A branch of science under the influence of correct 
classification and arrangement, resembles a stately edi- 
fice, complete in its parts, just in its proportions, har- 
monious in its composition, chaste in its ornaments, 
and capable of being compassed, in all its beauties, at 
a single view. Deprived of its classification, the same 
branch may be fitly compared to the same building 
shaken from its basis, and reduced to a shapeless pile 
of ruins, by a hurricane, an earthquake, or the opera- 



30 PRELIMINARY DISCOURSE. 

tions of war. It is now a mass of confusion, in which 
all affinity, and every principle of association are want- 
ing; or, if not actually wanting, incapable of being 
traced by the common observer: it cannot be viewed 
in its several parts without an examination that is pain- 
fully laborious: and, even then, it is seen only in de- 
tached parcels, to offend by its unsightliness, distract, 
and be forgotten. 

That we may be the better understood, let Zoology 
be the branch of science selected to illustrate and ex- 
emplify our meaning. Within the same inclosure let 
us suppose to be crowded together, without order or 
arrangement, individuals or pairs of all the several 
species of animated beings that the earth contains — 
man and quadrupeds, birds and fishes, reptiles and in- 
sects, shells and zoophytes. 

What a vast and incomprehensible scene of confusion 
the fancy here presents to our view! There appears 
to exist in it no common bond of union, nor any clue of 
affinity or resemblance, to lead us from a knowledge of 
one object to that of another, until the whole shall be- 
come familiar to us. On taking a survey of it, what 
observer would conceive himself capable of ever dis- 
tinctly remembering, and referring to, as a source of 
useful knowledge, the many thousands of jarring and 
heterogeneous individuals of which it is composed? 

Jjet this living chaos, however, but feel the touch of 
an enlightened Naturalist — let it be divided, according 
to strict systematic arrangement, into the classes, or- 
ders, genera, and species of which it is composed, and 
each species be placed next to that to which it bears 
the closest resemblance — let this be done, and imme- 
diately all confusion, and difficulty of comprehension 
are at an end. Every little group of beings exhibiting 
now an affinity to those around it, a chain is perceived 



PRELIMINARY DISCOURSE. 31 

which binds together in one great alliance the whole 
assemblage; while a clue is presented to the inquirer, 
calculated to lead him, by easy and natural gradations, 
from the knowledge of one part to that of another, 
until a perfect familiarity with the whole shall be at- 
tained. He no longer examines the multitude before 
him by individuals: he looks at it now by families or 
tribes, and learns, in a short time, to compass the whole 
at a single glance. 

It is thus that, in our progress through the rudiments 
of learning, we proceed from letters to syllables, from 
syllables to words, and from words to sentences, until a 
whole page is deciphered almost as soon as it meets the 
eye — so essential is the aid which classical arrange- 
ment affords us, in our pursuit of the knowledge of 
Zoology and letters. Nor is it less useful to us, as might, 
by analysis, be fairly demonstrated, in the study of any 
other branch or topic of science. 

It is true that Dr. Rush, whose opposition to metho- 
dical Nosology led us to engage in the composition of 
this discourse, acknowledged the general utility of clas- 
sical arrangement, but denied its applicability to the 
science of disease. It will appear, however, we appre- 
hend, on an examination of the subject, that his rea- 
sons for this denial were without weight. 

We have already observed, that the only true basis 
for a classical arrangement of objects, to whatever de- 
partment of nature they may belong, is a permanent and 
perceptible affinity between them in some points, and a 
dissimilarity in others. We shall now add, that all ob- 
jects, thus relatively characterized, are susceptible of 
such arrangement. 

Is this definition applicable to diseases? Are the va- 
rious morbid phenomena to which the system of man is 
liable, so marked in relation to each other, as to be 



32 PRELIMINARY DISCOURSE 

plainly and uniformly similar in some points, and dissi- 
milar in others? If so, they are, in their nature, as 
susceptible of a methodical arrangement, as the objects 
of the animal and vegetable kingdoms. 

To physicians of experience, observation and thought, 
this topic of inquiry must be already sufficiently clear: 
to the inexperienced but sensible student of physic, we 
trust there will be found but little difficulty in render- 
ing it so. 

The human body is known to be a compound ma- 
chine, consisting of various subordinate parts, which 
differ not a little from each other in their structure, func- 
tions, and uses. Of these parts it will be sufficient for 
our present purpose to enumerate, the skin, the muscles, 
the brain and nerves, the heart and blood-vessels, the 
absorbents, the glands, the stomach and alimentary ca- 
nal, and the bones. 

It is further known that these subdivisions of the 
body are susceptible of disease, either severally in par- 
cels, or all at once. The latter, however, is a phenome- 
non which does not, perhaps, very often occur. An uni- 
versal disease, in which no part of the system escapes, 
we have rarely witnessed. 

The whole, or a great proportion of the body may 
be also diseased, in a certain degree, while a still higher 
and severer complaint exists in some one of the subor^ 
dinate parts. This is more especially the case in Dr. 
Cullen's Order Phlegmasiae. But the same thing is also 
true of all febrile diseases that are accompanied with 
a topical affection — of the Exanthemata, the Hemor- 
rhagise, the Profluvia., and even many of the class Neu- 
roses. 

As all the subordinate parts of the body differ from 
each other essentially in their structure, functions and 
uses, it follows, of absolute necessity, that they must 



PRELIMINARY DISCOURSE. 33 

be subject also to different diseases.* They are not 
organized alike; they act, and, whether sound or un- 

* This is true not only of the various organs of the body, but of the dif- 
ferent structures of which they are composed. 

The primitive structures are four, the serous, the mucous, Xheji/jrous, and 
the cellular, each differing from the other in its organization, its susceptibi- 
lity, and its power of action. 

This lays the foundation for a radical difference in the character of dis- 
ease, according to the structure in which it is seated. 

Diseases are essentially modified by the powers of action of the parts 
they attack. Even when they both proceed from the same cause, a com- 
plaint situated in a mucous, differs materially from one that has its seat in a 
serous membrane, while, if it attack a fibrous or a cellular structure, it ex- 
hibits still a further difference. 

Catarrh and pleuritis vera are both inflammatory complaints, and often 
arise from the same cause. But they are exceedingly different in their cha- 
racter, because the former is seated in a mucous, and the latter in a serous 
membrane. 

For the same reason dysentery and diarrhoea differ widely from enteritis, 
and gonorrhoea from an inflammation of the peritoneum or the skin. 

Rheumatism and colic are affections of the Jibrous, and differ essentially 
from phlegmonic inflammation, and every other disease that has its seat in 
the cellular structure. ' 

But it is not on the difference of structure alone that disease depends for 
its immense variety. It is modified in a still higher degree by the differ- 
ence of its causes. 

Disease is the result of morbific stimulation on some portion of the body. 
But all stimulants are, in their nature, essentially different from each other. 
They are all, in the strict sense of the term, specifics, and produce, when 
applied to living matter, each a kind of action corresponding with its own 
peculiar character. 

The matter of small-pox is essentially different from that of measles, the 
matter of bilious from that of typhus fever, and the matter of syphilis from 
that of kine-pox, while, between all the animal, vegetable, and mineral poi- 
sons, whether veriform or fixed, similar differences are known to obtain. 

Considering, then, the existence of two such powerful and prolific 
sources to give diversity to disease, how infinitely preposterous is that doc- 
trine, which proclaims its " unity !" No less wild and unwarrantable would 
it be to assert the unity of the vegetable kingdom! 

When human physiology shall have been better understood, important 
improvements in the practice of medicine will arise out of a perfect know- 
ledge of the susceptibilities and sympathies of the four primitive structures 
of which the body is composed. 

It will then be fully known, as it is now in part, that those structures are 
specifically impressed by agents specifically different from each other, and 
tbat each structure has a peculiar affinity or aptitude to be acted on by its 
own kindred class of remedies. 

VOL. I. E 



S4 PRELIMINARY DISCOURSE. 

sound, must act, in a manner corresponding to their 
organization; disease is the morbid action of organized 
parts; their diseases, therefore, cannot be alike. 

Without any further reasoning to support it, this po- 
sition might be assumed and rested on as a physical 
axiom. To the enlightened pathologist it is a self-evi- 
dent truth. As well may the mechanic look for the 
same kind of action, whether sound or disordered, in 
a steam-engine and a watch, a water-mill and an orrery, 
however dissimilar these productions of art may be in 
their structure, as the physician in the different subdi- 
visions of the body. 

This point being exceedingly important to the deci- 
sion, and even to the proper understanding of the pre- 
sent controversy, we shall, for the more satisfactory 
illustration of it, dwell on it further, and treat of it more 
in the form of analytical detail. 

The structure and the healthy action and functions 
of the skin and muscles being radically different from 
each other, because they are intended to subserve, and 
do subserve, different purposes in the animal economy, 
it is physically impossible that their diseased action 
should be the same. — Nothing short of a miracle — 

Thus terebinthinales manifest a specific predilection for the mucous 
structure. Hence their salutary effects in catarrh, gonorrhoea, fluor albus, 
and other complaints of a similar character. 

On the fibrous structure, act with a specific effect narcotics and antispas- 
modics; while sudorifics and diuretics throw their influence more especially 
on the serous structure. 

These latter articles act also, to a certain extent, on the cellular struc- 
ture. Touching specific remedies, however, for the structure, we do not 
profess to speak with certainty. 

From considerations contained in this note, we feel persuaded, that fu- 
ture improvements in the practice of medicine are destined to arise, not 
out of additions to be hereafter made to materia medica, but from the admi- 
nistration, or correct principles, of the remedies we possess. 

All medicinal substances are, in their nature, specifics, and, to do the good 
of which they are capable, must be administered under a knowledge, not 
merely of their general operation, but of their specific effects. 



PRELIMINARY DISCOURSE. 35 

something, at least, subversive of the usual processes 
of nature — could render them so. Simply to state this 
position is definitely to prove it. Arguments would be 
wasted in an attempt to elucidate or strengthen it. No 
man of a sound intellect will expect to find the same 
disorder in the rigging of a ship and the wheels of a 
clock. The reason is obvious. The machinery is dif- 
ferently constructed, because designed for different pur- 
poses. The disorders incidental to it must be also dif- 
ferent. So in relation to all conditions of the skin and 
the muscles of the human body. Their action, whe- 
ther diseased or sound, cannot be alike, because the 
organic structure of the parts is dissimilar. 

The same thing is true with respect to the heart and 
blood-vessels, and the brain and nerves. The organiza- 
tion and healthy action of these parts are utterly dissi- 
milar; so also are their uses: it would be contrary, 
therefore, to every principle of reason, and every esta- 
blished rule of philosophizing: to allege that their dis- 
eases can be alike. They must be different, or nature 
is palpably inconsistent with herself. 

Who will be so weak as to assert that the same kind 
of disease can prevail in the intestines and in the bones? 
— in an absorbent and in the optic nerve? — in a gland 
and in the nerve of hearing? — parts so fundamentally 
different from each other, not only in structure, but in 
all the attributes and properties of life. With equal rea- 
son and probability of success might an attempt be made 
to maintain the identity of a man and an elephant, or a 
lion and a whale. 

Thus might we examine in detail the whole of the 
human system, and show, that from a necessity as in- 
flexible as the principles of nature, different parts of it 
must be subject to different diseases. To maintain the 
contrary would be to pronounce causes, totally dissimi- 



36 PRELIMINARY DISCOURSI- 

lar in their principles and modes of action, capable of 
producing similar effects. 

A disease consists in the suspension or disorder ot 
one or more of the functions of the body. It must be 
widely different, therefore, in different instances, ac- 
cording to the function thus affected. 

An unsound state of the functions of the lungs pro- 
duces a disease widely different from that which arises 
from an unsound state of the functions of the stomach. 
If the functions of the liver be disordered, the disease 
is equally different from that which a disorder in the 
functions of the kidneys excites. Nor, when the func- 
tions of the eye are shattered or destroyed, will any one 
contend that the disease is the same with that which 
results from a similar affection in the functions of the 
ear. These are truths so nearly self-evident, that, un- 
supported by the weight of argument or authority, they 
may be safely left to defy the devices and powers of 
sophistry. The extent to which they might be mul- 
tiplied by a further analysis, will be readily perceived 
by the enlightened pathologist. They might be render- 
ed as numerous as the several organs or parts of the 
body, which differ from each other in their functions 
and uses. 

A very fertile source of difference between the dis- 
eases of the several organs of the body, arises from the 
different sympathies which these organs possess with 
the system at large. A local affection of the stomach 
produces a disease widely different from a similar af- 
fection of the lungs, because the sympathies of the two 
organs are equally different. The uterus possesses 
sympathies with the rest of the system different, in a 
high degree, from those of the liver: the affections of 
these two organs, therefore, cannot be alike in their 
nature or consequences. The same thing might be 



PRELIMINARY DISCOURSE. 37 

said of the kidneys and spleen, the brain and heart, and 
of various other organs of the body, were it necessary 
to enumerate them. 

The diseases to which we have, as yet, had reference, 
must be regarded as somewhat limited in their extent. 
The dissimilarity between those of a more general cha- 
racter may be demonstrated with equal facility and 
certainty. 

A febrile disease cannot fail to be different in its na- 
ture and character, according to the part of the system 
in which it is radicated, and on which it expends its 
principal force. A fever having its topical affection in 
a vascular part, is necessarily different from one which 
topically attacks the brain or nerves. In other words, an 
inflammatory is different from a nervous or typhus fe- 
ver. Equally different is a fever radicated in the sto- 
mach from that which throws the force of its action on 
some of the glands or the skin: while those invading 
the bowels, or commencing there in the form of diar- 
rhoea, and in that portion of the Schneiderian mem- 
brane which lines the fauces and the bronchiae, are 
different from both. 

Thus far we have reasoned a priori; or, in language 
less technical, from first principles; and hope that our 
arguments have neither been unsound, nor our conclu- 
sions illegitimate. 

But perhaps we might most decisively establish our 
position, by somewhat inverting ouf rule, and, instead 
of merely inferring the diversity of diseases from the 
existing diversity in the nature of their seats, prove it 
from the difference of their signs and symptoms. 

The more, clearly to demonstrate the fairness of our 
reasoning, we shall iiere premise, that, from an acknow- 
ledged inability to penetrate the nature or essence of 
things, we are forced to judge of them from external 



38 PRELIMINARY DISCOURSE. 

appearances. Nor can we pretend, in general, to the 
slightest knowledge of them, except what these appear- 
ances communicate. To illustrate our meaning by a 
familiar example. 

• In pursuing our studies in the science of nature, out- 
ward appearances constitute our principal, in most in- 
stances, our only guides to knowledge. We are, there- 
fore, compelled to have recourse to their aid, and to 
place confidence in the truth of the information they 
impart. Henpe it is, that where we find objects uni- 
formly different in their external qualities, we are for- 
bidden to doubt that they are different in themselves. 
While, on the other hand, the only evidence we can 
possess of actual identity, is identity of appearance. 

To be still more explicit on this subject. When we 
find two objects — vegetables, for example — the same in 
size, in figure, in colour, in blossom, in fruit, in habit, 
in smell, and in taste, we conclude, without hesitation, 
that they are the same in species. Nor is there any one 
so hardy as to call in question the correctness of our 
decision. The same thing is true in relation to subjects 
of the animal and mineral kingdoms. Identity in all their 
discoverable qualities is received as evidence of identity 
in their nature. The reverse of this rule is equally un- 
questionable. An invariable difference in the qualities 
herein specified is regarded as indicating conclusively a 
difference in the genera or species of animals, vegetables, 
and minerals. 

By enlightened pathologists the same rule of investi- 
gation is admitted as perfectly applicable to diseases. In 
common with the regular productions of nature, these 
morbid conditions of the body can be studied only 
through the medium of their phenomena or external 
qualities. But the only external qualities which they 
possess are their signs and symptoms. A sameness in 



PRELIMINARY DISCOURSE. 39 

these manifests a sameness of origin, while an invari- 
able difference in them never fails, nor can it, indeed, 
fail, to be received as evidence, satisfactory in itself, of 
a radical difference in the nature of the diseases to 
which they belong The same disease can no more 
exhibit different phenomena or characteristic symptoms, 
than the same plant can exhibit a difference in its own 
fruit and figure, its flowers and foliage. 

These truths are already so clear, that, by those who 
are versed in the science to which they belong, an at- 
tempt to render them more so might be deemed super- 
fluous. They are a fair and perspicuous interpretation 
of the language of nature, in relation to the subject 
whereof we are treating. But in a case where funda- 
mental principles are concerned, nothing should be left 
to fancy or conjecture. We deem it our duty, there- 
fore, to adduce a few examples illustrative, and, at the 
same time, confirmatory of the doctrine for which we 
are contending. 

According to the correct rule of philosophizing, a 
febrile disease marked with an acute pain in the thorax, 
a difficulty of respiration, a violent cough, and a frothy, 
puriform, or sanguineous expectoration, is essentially 
different from a case of fever unaccompanied by such 
topical affection; much more does it differ from one, 
which, to an exemption from any local thoracic com- 
plaint, adds a general pustulous eruption on the surface 
of the body. For the reason why these diseases must 
be pronounced different no one can be at a loss. It 
is because their perceptible and characteristic qualities, 
from which alone we derive our knowledge of them, 
are essentially different. Nor can any thing induce us 
to consider them the same, unless it be some delusive 
hypothesis, which fairly cheats us of the testimony of 
our senses. 



40 PRELIMINARY DISCOURSE. 

On no ground of evidence or principle of reason can 
a disease marked by tormina or severe gripings, a con- 
stant and distressing tenesmus, frequent mucous, puri- 
form, or bloody discharges from the bowels, and pro- 
duced by an exposure to atmospheric impurities, be 
considered the same with one arising from a puncture 
in the foot or hand, and characterized by an immobility 
of the lower jaw, a stitfness of the neck, a difficulty of 
swallowing, a constipation of the bowels, a distressing 
pain in the epigastric region, and general convulsions 
frequently recurring, or an entire rigidity of the body 
and limbs. The discriminating characters of a horse 
and a lion, or of a serpent and a dog, are not more 
strikingly perceptible, nor more widely different from 
each other, than those winch mark the distinction be- 
tween these two diseases. Nothing, therefore, short 
of absolute ignorance in medicine, or some profession- 
al hallucination bordering on madness, can induce any 
one to pronounce dysentery and tetanus to be the same 
disease. 

Observations precisely similar may be made in rela- 
tion to scrophula, which is an affection of the glands, 
and erysipelas, which is a peculiar inflammation of the 
skin; diarrhoea, a complaint of the bowels, and regular 
gout, which is topically seated in the foot; rheumatism 
a disease confined to muscular, ligamentous, or other 
soft parts, and rickets, which perpetrates its ravages on 
the bones. The peculiar marks, by which alone these 
several diseases can be known, are essentially different 
from each other. It is a disregard of evidence, there- 
fore, amounting to a breach of moral obligation, seri- 
ously to contend that the diseases are the same. 

By passing, in this manner, through the whole cata- 
logue of diseases comprised in the systems of judicious 
nosologists, we might show that they are all distinguish- 



PRELIMINARY DISCOURSE. 4] 

ed from each other by characters sufficiently percepti- 
ble and definite, to be recognized by every one, and to 
answer the purposes of a classical arrangement. 

Before taking leave of this head of our subject we 
shall further observe, that whatever set or family of 
morbid symptoms we find associated together with a 
constancy and regularity that do not belong to accident, 
but comport with the steadiness of a law of nature, we 
are bound to consider as arising from a common and 
distinct cause, and as constituting necessarily a separate 
disease. Should this association of symptoms be py- 
rexia, ushered in by a harsh, dry and sonorous cough, 
and a red and watery state of the eyes, with an occa- 
sional sneezing, and succeeded on the third or fourth 
day by a scarlet-coloured eruption on the skin, we give 
it the name of measles: if it be a preternatural dulness 
and disinclination to motion, heartburn, nausea and an 
occasional vomiting of an acid gelatinous fluid, a cos- 
tive state of the bowels, an unusually light colour of 
the faaces, and a yellowness of the skin, accompanied 
at times with a troublesome itching, we regard it as 
constituting a different disease, and call it jaundice: 
and if it be a severe pain of the bowels, with a sensa- 
tion of twisting or knotting in the region of the navel, 
marked by occasional intervals of ease, and attended 
by obstinate costiveness and vomiting, we term it colic. 
It is thus that in the animal and vegetable kingdoms, 
we regard certain uniform and regular combinations of 
the external qualities of size, form, habit, colour, odour, 
and taste, as constituting distinct classes and orders, ge- 
nera and species. 

Having, as we flatter ourselves, satisfactorily establish- 
ed, in relation to diseases, one branch of the basis of a 
classical arrangement, viz. their radical difference from 
each other, it belongs to us now to make a few remarks 

vol. j. F 



12 PRELIMINARY DISCOURSE. 

on their affinities, which constitute, as we have already 
observed, the other branch. On this head oi" our sub- 
ject it is our intention to be brief; a detailed anal) sis 
of it being altogether unnecessary for the purposes we 
have in view. 

One circumstance which constitutes a point of strong 
analogy between the diseases we are considering is, 
that they are all incidental to the system of man. They 
consist, moreover, in a disorder, suspension, or entire 
destruction of one or more of the functions of health, 
and are accompanied with an increase or diminution of 
action and sensation, and a preternatural condition of 
muscular strength. Certain families or tribes of them 
commence with a chilliness, and an enfeebled state of 
the pulse, which are, in a short time, succeeded by in- 
creased arterial action, and inordinate heat. Of these, 
some assume a continued form; others exhibit regular 
periodical intermissions; some are free from any topical 
affection; others are marked by acute and violent pains 
in various parts of the body; a fifth order are accompa- 
nied with discharges of blood; and a sixth with various 
eruptions on the skin. 

As further points of affinity between certain tribes or 
families of diseases may be mentioned, preternatural 
discharges of fluids not sanguineous, disordered and 
irregular contractions of certain sets or systems of 
muscles, and an intumescence of various parts of the 
body. 

Sundry other marks of affinity might be here enume- 
rated; but the foregoing, we trust, will serve to show, 
that diseases are related to each other by ties sufficiently 
strong and diversified, to furnish ground for an associa- 
tion of them under a system of classical nosology. 

We might now proceed to speak of that plan of no- 
sological arrangement which appears most natural in 



PRELIMINARY DISCOURSE. 43 

itself, and best comports with the character of diseases. 
But it will, perhaps, be expected, that we should pre- 
viously take some notice of the objections urged by Dr. 
Rush against systematic nosology in general, and of his 
attempt to repudiate it from medical science. 

The objections of that celebrated teacher, in relation 
to this subject, might seem to have been numerous: 
but, when considered on principle, they are reduced to 
a point : they all derived their origin from a single 
source — the belief of their author in the unity of disease. 
Had it not been for the influence of that hypothesis, the 
professor would never have rejected classification, and 
renounced nosology. He possessed too correct a know- 
ledge of the value of system, and held in too high esti- 
mation arrangement and method, to have pursued, as 
the result of cool deliberation and an unbiassed judg- 
ment, a course of inflexible hostility to that, which alone 
brings order out of confusion and renders medicine in- 
telligible. 

But we ought, perhaps, to recal our expression. Dr. 
Rush did not, in reality, renounce nosology. His re- 
nunciation was in words, not in fact. He only ex- 
changed one plan of nosology for another — a more sim- 
ple, as we conceive, for a more complicated — a sub- 
stantial for a visionary — one founded in nature, or, at 
least, corresponding with many of the phenomena of 
disease, for one which appears to have been much more 
the creature of fancy than of reason. 

The nomenclature of diseases used by Dr. Rush, 
which was, in many instances, exceedingly forced and 
unnatural, was nothing but a substitute for a scheme 
of nosology. By a brief and fair analysis of the sub- 
ject, this may be proved to the satisfaction of the 
reader. 

To place this matter beyond the sphere of denial or 



44 



PRELIMINARY DISCOURSE. 



doubt, we will here give a comparative view of a por- 
tion of the nomenclatural arrangement of Dr. Rush, 
and the corresponding part of the nosological arrange- 
ment of Dr. Cullen. We shall begin with the differ- 
ent kinds, or, as Dr. Rush denominates them, states 
of fever, and, for the sake of discrimination, shall affix 
over each arrangement the name of its author. 



CULLEN. 

1. Intermittent fever. 

2. Synocha. 

3. Typhus mitior. 

4. Typhus gravior. 

5. Typhus Icterodes. 

6. Synochus. 

7. Hectica. 



RUSH. 

1. Synochus fortis. 

2. Synocha. 

3. Synochula. 

4. Synochoid. 

5. Synochus mitis. 

6. Intermittent. 

7. Hectic. 

8. Typhoid. 

9. Febricula. 

10. Suffocated or oppressed 
state. 

1 1. Prostrate state. 

12. Gangrenous state. 



Another suitable specimen of comparison may be 
derived from the nomenclature and arrangement of the 
diseases of the mind. 



CULLEN. 

VeSANIjE THE NAME OF THE 

OltDER. 

1. Amentia. 

2. Melancholia. 

3. Mania. 

4. Oneirodynia. 



RUSH. 
Diseases of the Mind. 

1. Seatou Mania. 

2. Allou Mania. 

3. General mania in its high- 
ly inflammatory state. 

4. Manicula. 

5. Manalgia. 

6. Fatuity. 

7. Defect and lossof memory. 

8. Dreaming. 

9. Phantasms. 

10. Absence of mind. 

11. Operations of the mind in 
a trance. 



We shall close this comparison with a view of certain 
diseases deriving their names from the parts of the 
body they particularly affect. 



PRELIMINARY DISCOURSE. 



45 



CULLEN. 


RUSH. 


(xastrilis. 


1. Gastritic state of fever 


2. Enteritis. 


2. Intestinal. 


3. Hepatitis. 


3. Hepatic. 


4. Diabetis. 


4. Diabetic. 


5. Haemorrhois. 


5. Hemorrhoidal. 


6. Cystitis (Inflammation of 


6. Cystic. 


the bladder.) 


7. Ophthalmic. 


7. Ophthalmia. 


8. Odontalgic. 


8. Odontalgia. 


9. Otalgic. 


9 Otalgia. 


10. Apthous. 


10. Apthae. 


1 1. Scrophulous. 


1 1. Scrophula. 


12. Scorbutic. 


12. Scorbutus (scurvy.) 


13. Convulsive. 


13. Convulsions. 


14. Hydrophobic. 


14. Hydrophobia. 


15. Hysterical 


15. Hysteria. 


16. Hypochondrical. 


16. Hypochondriasis. 


17. Cutaneous. 



Of this comparative statement, the tendency and re- 
sult are too obvious in themselves, to require for their 
illustration the slightest comment. They show with a 
clearness amounting to demonstration, that Dr. Rush 
has neither rejected, nor, in any one respect, improved, 
nosological arrangement. Or, if he has improved it, it 
is not by abridging and simplifying it, but by rendering 
it more complex and voluminous. 

Under the order of Fevers, properly so called, 
Dr. Cullen has enumerated seven kinds, and Dr. Hush 
twelve. 

The latter has eleven different kinds or forms of dis- 
eases of the mind, and the former only four. 

In the last instance of comparison, although the dis- 
eases on which the two professors have bestowed names 
are very nearly equal in number, Dr. Cullen is in no re- 
spect inferior to Dr. Rush in perspicuity of expression, 
and surpasses him not a little in classical brevity. His 
system is therefore entitled to a preference. 

Doctor Rush, in his nomenclature, expressly recog- 
nized the affinity of diseases. In his hydropic state of 
fever, his pneumonic state, his rheumatic state, his 



46 PRELIMINARY DISCOURSE. 

hepatic state, his cephalic state, and many others, the 
affinity consists in their being all possessed of a febrile 
character. But he, also, as expressly recognized their 
differences. These consisted in the difference of their 
determinations or topical affections. Were they not, in 
this respect, different, why designate them by different 
names? The measure, had he believed them to be the 
same, would have been altogether unwarrantable; be- 
cause it would have been giving sanction and currency 
to an error. 

It is true, he professes to consider these complaints as 
different farms of disease, instead of actually different 
diseases. But the distinction which he here attempts to 
establish, consists in words, not in substance. Perma- 
nently different forms of disease, occurring under differ- 
ent circumstances, occupying different seats, exhibiting 
different symptoms, attended with different degrees of 
danger, and requiring different modes of treatment, are 
as capable of being classed, as if they were specifically 
different diseases. Indeed, in .relation to all practical 
purposes, they are different diseases, and may, with 
propriety, be so denominated. 

Form is a quality so striking and attractive, and, in its 
relationship to every thing of which we have any know- 
ledge, so perfectly essential, that it alone is capable of 
constituting a radical and characteristic difference. 
This may be proved by innumerable examples. 

In what but form does a triangle differ from a square, 
an acute angle from an obtuse, a cone from a parallelo- 
gram, or an ellipsis from a circle ? In what else does a 
dagger differ from a sword, a bayonet from the point of 
a spear, or a trumpet from a French horn ? In what other 
than form does the body of a horse differ from that of 
an ox, the body of a dog from that of a goat, or the body 
of a lion from that of a tyger? — or, more forcible still, in 



Preliminary discourse. 47 

whst but fcm doe- the boHy of a man differ from either? 
We answer, in nothing that is by any means so important 
as form. Yet all these objects are capable of being 
clearly discriminated from each other, and methodically 
arranged in well defined classes, orders, and genera. 

Such precisely is the case in relation to diseases. To 
the mind of a pathologist, what Dr. Rush calls the hepa- 
tic state of fever, presents an image very perceptibly 
different from that presented by his pneumonic state — 
an image that can be realized and felt as a distinct ex- 
istence, with as much facility as can that of an oak or an 
eagle. With equal ease may the hydropic state of fever 
be discriminated from the rheumatic, the cephalic from 
the nephritic, and the gastritic from the ophthalmic. Had 
not this been the case, the doctor would have been guilty 
of the fault of using names without a meaning. These 
diseases, or, in the professor's own language, forms of 
disease, are, moreover, perfectly susceptible of classifi- 
cation and arrangement ; their affinities consisting in 
their febrile character, and their diversities in their 
topical affections, and the peculiar symptoms which 
these affections respectively produce. 

But, disregarding, for the present, his minor positions, 
we shall approach, at once, the stronghold of Dr. Rush's 
opposition to systematic nosology. This, as already 
stated, is his doctrine of the unity of disease — the con- 
viction of his own mind, with his arguments in support 
of it, that all diseases are essentially the same. 

If this main ground of his opposition, the citadel of 
his strength, can be taken from him, and shown to be, 
in its nature, utterly untenable, his posts and outworks 
established for its defence, must be surrendered of 
course. 

If we rightly understand the professor, in his attempt 



48 PRELIMINARY DISCOURSE. 

to explain himself, the following is a brief of his reason- 
ing on this subject. 

I. All diseases consist in morbid excitement. 

II. Morbid excitement is an unit,* because it is the 
product of stimuli or irritants acting on excitability. 

III. Therefore all diseases are an unit. 

Such we believe to be the syllogistic structure on 
which alone rests the doctrine of the unity of disease. 

When correctly analyzed, this form of argument will 
be itself found to consist of two fundamental and distinct 
assumptions — the unity oj excitabiliti, — and the unity of 
stimuli. These assumptions are fairly and necessarily 
implied in the middle proposition of the syllogism. 

If it be true, that excitability is, in every part cf the 
body, and under all circumstances, the same, and that all 
stimulants capable of acting on it are also the same, it 
follows, of necessity, that the result of this action can be, 
in no case, dissimilar — Disease must, then, be an unit, 
differing from itself, under different circumstances, in no 
other respect than that of its force. These two assumed 
propositions it shall now be our business to analyze and 
examine. 

From facts and reasonings which were submitted to 
the consideration of the reader, in a preceding part of 
this discourse, it is contrary to the fundamental princi- 
ples of our nature, that excitability should be, in all parts 
of our systems, the same. The hypothesis is one of the 
offensive crudities of the Brunonian doctrine, and ap- 

* The Brunonian doctrine on the subject of excitement, embracing, as it 
does, the unity of that property, is inconceivably absurd. It amounts to an 
extravagance of folly, which almost surpasses the limits of belief. Accord- 
ing to this sectarian doctrine, life consists in excitement, health in excite- 
ment, and disease, in excitement. Yet excitement is an unit : therefore life, 
health, and disease are the same. This is no misrepresentation, nor even 
exaggeration of the doctrine: it is the doctrine expounded precisely as it is 
maintained. 



PRELIMINARY DISCOURSE. 49 

pears to be utterly repugnant to all that we know of 
physiological truth. 

Although we do not believe that excitability derives 
its existence from the mere organization of matter — for 
it is a quality of matter not organized — we feel, notwith- 
standing, confident, that it is greatly modified by it. So 
also is the capability of action — we mean the capability 
of a part to assume any particular form or mode of ac- 
tion. These facts are of primary importance in the 
present discussion. 

Were excitability the same in every part of the body, 
it would, in each, be acted on by the same stimulants, 
and in the same way. The fact, however, is otherwise. 
Light, a powerful stimulus to the eye, and indirectly to 
certain other parts, produces no excitement in the organ 
of hearing; nor does air on the organ of vision. Augment 
their force to any degree that is practicable, the result is 
still the same. Air and light, therefore, differ as stimuli, 
or the eye and ear differ in their excitability. In either 
case the argument is in our favour: for, to prove the 
unity of disease, the unity of stimuli as well as that of 
excitability must be conclusively established. 

Nothing will act on the olfactory nerves but odours, 
nor on the nerves of taste but sapid bodies. Here again 
is something specific in relation either to excitability or 
stimuli. If there were not a radical difference in the 
excitability of these two sets of nerves, the same stimu- 
lants would act, and act alike, on them both. If there 
were not something specific in the nature of odours, 
they would not be alone capable of awakening the sense 
of smell; nor would sapid bodies be alone capable of 
exciting taste, unless they were different in their na- 
ture from other stimulants. Heat, cold, and all other 
stimulating agents produce sensation in the tongue and 
nares; but not the sensation of taste or smell. These 

vol. 1. g 



50 PRELIMINARY DISCOURSE. 

two latter sensations, therefore, can be nothing else than 
the result of specific stimuli acting on specific excita- 
bility. With equal correctness might similar obser- 
vations be made in relation to the nerves of touch. 

The organs of the five external senses, then, exhibit 
so many unequivocal examples of specific excitability. 
They, in this respect, differ from each other and from 
the rest of the system, as essentially and palpably, as 
silicious differs from argillaceous earth, an oak from an 
elm, or a bear from a buffaloe. 

The excitability of the stomach is very strikingly, 
and we believe, specifically, different from that of the 
lungs, the intestines, the lacfceals, and the blood-vessels. 

Many purgatives and other articles which pass through 
the stomach, if not entirely unfelt, at least, without much 
inconvenience, produce in the bowels the utmost dis- 
order. Bile the stimulus of which is necessary to the 
healthy and efficient action of the intestines, cannot be 
received into the stomach without giving rise to nausea 
and vomiting. 

Carbonic acid gas, which is to the stomach a grateful 
and salutary stimulus, proves immediately fatal when 
applied to the lungs. This can be attributed to no other 
source than a difference in the excitability of the two 
organs. 

Such is the peculiar excitability of the lacteals, that 
they reject at once the undigested alimentary matter, 
which is received without reluctance or injury by the 
stomach and intestines. 

The blood appears to be the only stimulus that can 
be at all tolerated by the internal surface of the heart, 
arteries and veins: every other substance brought into 
contact with that extremely delicate portion of our sys- 
tem produces convulsions and sudden death. But if a 
portion of blood be received in a crude state into the 



PRELIMINARY DISCOURSE. 5\ 

stomach, it rarely fails to prove the cause of sickness, 
and perhaps vomiting. The existence of different spe- 
cies of excitability can alone explain these phenomena. 

The lips, the organs of generation, and the female 
breasts, manifest, also by incontestable evidence, the 
existence of specific excitability. They are each capa- 
ble of being acted on by stimuli that do not at all affect 
the others. 

Were we to embrace in this analysis the whole of the 
human body, and give a complete history of the excita- 
bility of every particular part of it, our work would 
consist of little else than a record of differences. No 
two portions of the body that are differently organized 
would be found to be alike in their excitability. Nor 
does it appear possible that the case can be otherwise. 
We should as soon expect parts differently organized 
to be similar in their functions as in their excitability — 
as soon expect the skin to act like the glands, the 
glands like the muscles, the muscles like the nerves, 
the nerves like the blood-vessels, and the blood-vessels 
like the absorbents, as the whole or any two of these 
parts to be similar in their excitability. 

It is evident, then, that one of the assumptions, on 
which rests the doctrine of the unity of disease, viz. the 
unity of excitability, is utterly unfounded. We shall 
proceed to a brief examination of the other, viz. the 
unity of stumuli. 

Of the essence of stimuli we know nothing. We can 
judge of them only by their external qualities, their 
properties, and their effects. If they be alike in these, 
we must consider them alike in their nature; and if dis- 
similar in these, dissimilar in their nature. From this 
rule of inference it would be unphilosophical to depart. 
Let it be applied to the solution of the present question. 

In the properties of weight and hardness, elasticity 



j2 PRELIMINARY DISCOURSE. 

and cohesion; and in the external qualities of figure and 
colour, smell and taste, no two stimulants are precisely 
alike. In these respects, opium, alkohol, and ether are 
unlike wine, volatile alkali, and Peruvian bark ; prepa- 
rations of mercury unlike preparations of steel; Glau- 
ber's salts and castor oil unlike senna and rhubarb: 
asafoetida and musk unlike castor and camphor ; and 
cantharides and spirits of turpentine unlike every other 
substance with which we are acquainted. The same 
thing is true with respect to all stimulating substances, 
of which we have any knowledge, and the properties 
and external qualities of which we are capable of exa- 
mining. No two of them are precisely alike. Consider- 
ed in their resemblance to each other, therefore, they ex- 
hibit none of the characters of unity. 

If we examine them with a view to their operation on 
living matter, the isaue will be found in an equal degree 
unfavourable to the hypothesis we are opposing. When 
applied to the human body, whether in a diseased or a 
healthy condition, they are far from being marked with 
an identity of effect. On the other hand, out of the 
whole catalogue, no two can be selected that act pre- 
cisely in the same way. Although they all timulate, yet 
each one acts witli some modifications peculiar to itself. 
Of this fact no physician of experience can be ignorant. 
Opium and its several preparations stimulat ; but, in 
doing this, they relieve pain in a manner superior to all 
other remedies, and also in a different mode. It is in 
vain to assert, with Brown and his followers, that they 
differ from wine, aikohol. and ether, only in being more 
powerful and diffusible in their effects. The assertion 
is contrary to universal experience. Opium is daily 
exhibited, with great advantage, in cases of topical in- 
flammation, and other diseases, wherein wine, ardent 
spirits, aromatics, and all kinds of stimulating aliment 



PRELIMINARY DISCOURSE. 53 

and drink would be injurious. In relation to its effects 
on living matter, opium is a substance sui generis. If 
certain articles of materia medica resemble it, in some 
respects, in their mode of action, they differ from it 
widely and essentially in others. 

Mercury stimulates: but, in its action on the salivary 
glands, it is altogether unique. The stories we hear, of 
a like salivation being produced by other substances, 
are either unfounded, or the effect is to be attributed to 
some peculiarity in the systems of those in whose cases 
it has occurred. The event cannot be regarded in the 
light of a general and settled principle. Although 
many articles, when chewed, produce a temporary dis- 
charge of saliva, mercury is the only permanent sialo- 
gogue. 

A further and very striking example of the specific 
operation of stimuli is furnished by cantharides. Other 
articles, when applied to the skin, produce vessication: 
but it may be confidently asserted, that, in its entire 
operation, no one exactly resembles this. It is a medi- 
cinal substance specific in its character. 

The history of the external senses furnishes exam- 
ples, conclusive in themselves, of the diversity of stimu- 
lants. Were the doctrine of the identity of these 
agents true, the different colours which objects present 
to the eye, would be wholly inexplicable. No one will 
contend, that, by any modification in its force, a blue 
ray of light Can be made to produce on the optic nerve 
the sensation of redness, a red ray that of orange, or an 
orange ray that of yellowness. Each of these sensa- 
tions, as well as those of the remaining colours, can 
arise only from the specific peculiarity of the stimuli 
that produce them. 

Similar observations may be made in relation to the 
operations and functions of the tongue. The leading 



54 PRELIMINARY DISCOURSE. 

tastes of sweet, sour and bitter, with all the numerous 
intermediate sensations, give testimony, which nothing 
can resist, of the diversity of stimulants. An identity 
of impression can never produce them. 

Nor are the innumerable and peculiar diversities of 
odours and sounds less pointedly in favour of the doc- 
trine we are defending. The different kinds of organic 
action on which they depend, can arise only from a cor- 
responding difference in the stimulating agents by which 
they are excited. 

Certain stimulating substances are, in their effects, 
not only different, but in direct opposition to each other. 
Rhubarb, aloes and gamboge stimulate and purge; sac- 
charum saturni, opium, and Peruvian bark, stimulate 
also, but produce costiveness. Tartarized antimony, 
ipecacuanha and vitiiolated zinc, stimulate and excite 
vomiting; seltzer water, an infusion of mint, and a mix- 
ture of brandy and water also stimulate, but check vo- 
miting. Squills and digitalis stimulate and give rise to 
an increased secretion of urine; opium, cicuta, hyoscy- 
amus, and perhaps the whole family of the narcotics, 
stimulate in like manner, but diminish the secretion of 
urine. 

Certain cordial articles, as wine, brandy, and savory 
food, when received into the stomach of a person weak- 
ened by hunger, stimulate its coats and produce an im- 
mediate augmentation of strength; but arsenic, crystal- 
ized muriate of mercury, and the juice of tobacco, 
stimulate also in a very high degree; yet, when taken into 
the stomach, they diminish strength. This difference 
in result must be owing to the different modes of action 
of the substances employed. The former class consists 
of salutary stimuli, which, when skilfully administered, 
always give vigour; the latter of deleterious ones, which, 
when swallowed in sufficient doses, never fail to take it 
away. 



PRELIMINARY DISCOURSE. 55 

There is yet another source of diversity in the opera- 
tion of stimuli, to which we have not heretofore suffi- 
ciently adverted It is their peculiar fitness for acting, 
some on one, and some on another, of the subdivisions 
of the body. An attempt has been made even to class 
the articles of the materia medica on this principle. 
Opium acts chiefly on the brain and nerves; mercury 
on the glands and lymphatics; wine and aromatics on 
the heart and blood-vessels; preparations of steel on the 
stomach; and squills, digitalis, and uva ursi on the kid- 
neys. 

On what but a conviction of their diversities, do wri- 
ters on materia medica found their division and classi- 
fication of stimulants? — representing them to consist of 
astringents and tonics, corrosives and antispasmodics, 
errhines and sialagogues, expectorants and emetics, 
cathartics and diuretics, diaphoretics and emmena- 
gogues, and some others? Were all these articles the 
same, such a classification would be nothing but a tis- 
sue of systematized error, disingenuous in its nature 
and delusive in its effects. Yet, singular and inconsis- 
tent as it may appear, it was adopted by Dr. Rush in 
his lectures on therapeutics. Hence, in a practical 
point of view, that teacher supported the doctrine of 
the diversity of stimulants, although, theoretically, as an 
unitarian in pathology, he was an advocate for their 
identity. Against his favourite hypothesis, therefore, 
he leaves us the weight of his own authority. 

There evidently exists, then, a two-fold ground of 
difference in relation to the result of the operation of 
stimuli; a difference in the qualities of the articles them- 
selves; and a difference in the susceptibility and struc- 
ture of the parts on which they are peculiarly fitted to 
act. These grounds are, each in itself, unfriendly to the 



56 PRELIMINARY DISCOURSE. 

doctrine of the unity of disease, and, when united, 
necessarily fatal to it. 

From what we know of Nature, we are bound to be- 
lieve that she does nothing in vain. But, were all 
stimuli the same, where would be the use of such an 
extended catalogue of thorn as she has offered to our 
selection? Why should they superabound in the animal, 
vegetable, and mineral kingdoms? In a medical point of 
view, at least, this profusion would be superfluous, and 
even embarrassing. With one of them, as well as with 
the whole, might the physician fulfil every possible indi- 
cation of cure. Let him take, for example, common 
brandy, and, by dextrously varying the strength and 
dose of it, his business would be done. With this article 
alone he might purge or sweat, puke or salivate, pro- 
mote absorption or increase the action of the kidneys 
and other glands, according as the one or the other of 
these processes might be necessary. He might ev(m, 
as would at times be requisite, effectuate several indica- 
tions at once. 

A view of things more perverted by error, or more 
replete with absurdity than this, can scarcely be i; 
gined. Yet is it a correct picture of the issue to which 
the doctrine of the unity of stimulants necessarily lea-Js. 

Seeing, then, excitability is diversified, and stimulus 
diversified, and the several subdivisions and organs of 
the body incapable of acting alike, in consequence of 
the entire diversity of their structure, there exists in 
nature no shadow of foundation for the doctrine of the 
unity of disease. 

Thus far we have ventured to proceed, conducted by 
analysis, and directed on our way by the light of first 
principles. There remains to be considered another 
source of argument, more fatal, perhaps, to the hypo- 



PRELIMINARY DISCOURSE. 57 

thesis we are combating, than any to which we have yet 
Jia ; recourse, ft is the doctrine of specific poisons. 

With this doctrine before him, and possessing, as we 
think lie did, a perfect knowledge of it, it is somewhat 
more than singular — it is truly astonishing, that Dr. 
Rush should ever have contended for the unity of dis- 
ease — that he should have pronounced small pox and 
chicken pox. kine pox and lues venerea, measles and 
hoopmg-cough, the itch and the leprosy, to be the same 
malad* ! 

Was it not perfectly known to Dr. Rush, and is it 
not as well known at present, to his followers — if, in 
relation to tiiis point, he has any followers — that, with 
as much certainty as a grain of wheat produces a stalk 
of wheat, or a grain of oats a stalk of oats does the 
poison of small pox produce small pox and nothing else? 
the poison of kine pox. kine pox and nothing else? — 
and, that neither of these diseases can be brought into 
existence by the poison of lues venerea, the leprosy, or 
the itch? But causes are known by their effects; and 
different effects uniformly occurring under similar cir- 
cumstances, arise, of necessity, from different causes. 

Is it not a fact of universal notoriety, that persons who 
have been once affected by small pox, are not liable to 
it again, although their liability to other diseases re- 
mains unaltered? and does not this fact evince, by a 
force of evidence which nothing can resist, that small 
pox is different from every other complaint? If it were 
not different, why should the system be exempt from it 
alone, its susceptibility as to other maladies remaining 
unchanged? Were it like bilious fever, pleurisy, or 
rheumatism, wherefore should the s) stem, having once 
experienced it, be secure from it and liable to them. 

We shall illustrate this point by a familiar example. 
Twenty-four kinds of seeds uniformly take root and 
vol. 1. h 



58 PRELIMINARY DISCOURSE. 

flourish in a certain soil. A twenty-fifth refuses to 
quicken in the same soil, but vegetates freely in every 
other, producing a plant that bears no resemblance to 
any one of the twenty-four. Is not the last seed speci- 
fically different from all the others? So plain a question 
admits of but one reply.— Were there no objections to 
the unity of disease but those which small pox furnishes, 
they alone would subvert the doctrine. 

Again: — Disease consists in morbid action. If, there- 
fore, disease be an unit, morbid action must be also an 
unit. But the several morbific poisons — those, for ex- 
ample, of small pox, kine pox, and lues venerea, which 
have been already shown to be different from each other, 
because they give rise to different effects — are the pro- 
ducts of morbid action. Either, therefore, different 
products result from the same diseased action, or the 
diseased action which gives origin to these products is 
different. But the former branch of the proposition is 
unreasonable: the latter must be, therefore, admitted as 
correct. 

As well might we expect the same kind of generative 
action, in the animal kingdom, to be productive of an 
elephant and a hippopotamus, and in the vegetable, of 
an oak and a cedar, as the same morbid action which 
produces the poison of small pox, to be productive also 
of that of lues venerea. 

It must be regarded in the light of an axiom in pa- 
thology, that there are as many kinds of morbid action — 
in other words, of disease — as there are of morbific 
poisons resulting from it; each poison being the pro- 
duct of a corresponding specific secretory process. As, 
in health, the same kind of action which secretes bile 
from the blood, cannot secrete saliva, nor that which 
secretes urine secrete also the semen masculinum; 
neither is it possible for that morbid action which se- 



PRELIMINARY DISCOURSE. 59 

cretes from the blood the matter of small pox, to secrete 
also that of lues venerea: nor that which forms the 
poison of kine pox, to generate also the poison of 
leprosy. 

With all these truths — for so they must be called— 
arrayed against the hypothesis, it is to us, we repeat, a 
subject of astonishment, that Dr. Rush, or any of his fol- 
lowers, should have seriously contended for the unity of 
disease. The error appears to be as gross and gigantic, 
as any that is recorded in the annals of medicine. It is 
scarcely inferior to that fanatic delusion, which, in the 
days of Paracelsus, derived the contagion of pestilence 
from the moon. That it attracted proselytes at first, is 
sufficiently extraordinary: that it should retain them 
now, we think impossible. 

Against the hypothesis of the unity of disease, Dr. 
Rush has himself, we think, in sundry instances, fur- 
nished us with stronger and more conclusive arguments, 
than any other physician whose opinions are on record. 

In addition to the pulse of health, there are, as he 
assures us, twenty diseased pulses, each one of which is 
capable of being distinguished from all the others. 

Rut a pulse is nothing else than a state of action in an 
arterial tube — a diseased pulse being of course a dis- 
eased state of action. In Dr. Rush's opinion, then, the 
same artery is capable of manifesting twenty-one differ- 
ent kinds of action, of which twenty are morbid. 

Is this true of a single artery, and can it be, at the 
same time, true of the whole system, that, complex and 
varied as it is in its structure, it, as a compound, is ca- 
pable of taking on and exhibiting but one kind of ac- 
t on? — that a very simple and subordinate part of the 
machine can manifest, in its action, the variety of 
twenty; and yet, that the entire machine, consisting 



60 PRELIMINARY DISCOURSE. 

of at least twenty different parts, is capable, in its ac- 
tion, of nothing but impy? 

Unequal as we ourselves are to the difficulty of the 
task, it is to the followers of Dr. Rush that we are autho- 
rized to look for a solution, of this paradox. If they can 
make it appear, that both positions of their leader are 
true, \iz. that a single artery can exhibit twenty kinds 
of action, and the whole system but one, then, indeed, 
is the human body, in tlte language of the poet, and, in 
the true sense of the terms, the " riddle of the world !" 

Thus far have we endeavoured to show, on d- ctrinai 
grounds, the /(diary of the hypothesis of the unity of 
disease. It is our duty to add, that, in a practical point 
of mew, it is < minently danga'tnis. 

On the accuracy and perfection of the discrimina- 
tion of diseases, rest entirely the safely and success of 
the practice of physic. We must, therefore, be permit- 
ted to add, that that physician who would venture to 
treat *all diseases as if they were the same, would be 
unworthy to be intrusted with the care of any. His 
practice would itself prove a source of mischief as 
fruitful as the complaints he might be called to attend. 

Such a practitioner enters the room of a patient, la- 
bouring under apoplex) or gout in the stomach, inflam- 
matory rheumatism or bilious colic. Misled by the de- 
lusive notion of the unity of disease, he pronounces 
the complaint to be the same as intermitting fever or 
lues venerea, and attempts its removal by bark and 
wine, or the exhibition of mercury. The issue of his 
practice we need not mention. If it be not death, the 
siek man will be indebted for his escape, not to the 
skill of his physician, but to the strength of his own 
constitution, or the kindness of heaven. 

In a word, that physician who firmly believes in the 



PRELIMINARY DISCOURSE. $J 

unity of disease, and perse veringly practises in confor- 
mity to his belief, can scarcely fail to be in the daily 
violation of that divine precept, which forbids our be- 
ing instrumental in the taking away of human life. 

Having thus, as we conceive, by demonstrating the 
fallacy of the unity of disease, demolished the strong- 
hold of the professor's argument against classical noso- 
logy, it would be superfluous to pursue him through 
the details of his opposition. When the citadel has 
fallen, the outworks must be surrendered as a matter 
of course. 

We had designed, after closing this discussion, to 
enter on a critical examination of the merits and de- 
fects of the several s) stems of methodical nosolog} that 
are now extant. But the protraction of our discourse 
considerably beyond the limits we had assigned to it, 
compels us, for the present, to relinquish our intention. 

We shall, therefore, content ourselves with briefly 
observing, that, in the main, we consider the system of 
Di. Cullen as entitled to a preference over all others. 
W e think it more correct in its principles, more com- 
prehensive in its outline, more perspicuous in its ar- 
rangement, and much more simple and natural in its 
details. To aid in restoring to medical science in the 
United States, by means of that system, somewhat of 
the classical character, which, through the writings and 
teachings of Dr. Rush, it has been rapidly losing, con- 
stitutes w ith us a leading object in becoming the editor 
and commentator of the present work. 

But valuable as the nosological system of Dr. Cullen 
is, its faults are numerous, and several of them conspi- 
cuous. Were we to pass them unnoticed, we should 
be unfaithful to our duty. A brief consideration, there- 
fore, of some of the most important of them shall close 
our discourse. 



62 PRELIMINARY DISCOURSE. 

Were it our purpose to be rigid and fastidious in 
our critical remarks, we should not pass without con- 
demning, what we consider as an error in Dr. Cullen's 
definition of the first Order of his class Pyrexia. The 
classical pathologist will recollect that it is the order 
Febres, to which we allude. The following is the Pro- 
fessor's definition of it. 

" Proegressis languore, lassitudine, et aliis debilitatis 
signis, pyrexia sine morbo locali primario" 

The clause in this definition, which, strictly speak- 
ing, we think objectionable, is that printed in Italics. 
Although the Febres of Dr. Cullen exhibit no topical 
affection so strongly marked, as his Phlegmasia? do, it 
is, notwithstanding, incorrect to represent them as en- 
tirely destitute of such a character. All fevers are, at 
Jirst, nothing more than topical affections. They be- 
gin at a point, that point being the spot first injured by 
the morbific cause, and extend by sympathy, until they 
occupy the whole system. They are truly, as Dr. Dar- 
win represents them, diseases of association. An idio- 
pathic fever, in the sense in which it is usually under- 
stood, is, strictly speaking, a creature of the fancy. It 
has no more an existence among the works of nature, 
than a Polypheme or a Chimasra, a Harpy or a Ca- 
liban. 

Fevers may be compared to vegetables, the spot ori- 
ginally attacked being the root, on which the stem and 
branches depend for sustenance. Destroy or remove 
the root, the stem and branches necessarily wither. In 
cases of fever, heal, in an early stage, the first injury, 
which is the cause of all that follow* and its effects 
will disappear. It would seem U be essential, there- 
fore, to the existence of the complaint, that, for a time, 
at least, the part originally injured should retain the 
character of a topical affection. This radix, or point 



PRELIMINARY DISCOURSE. 6S 

of beginning, is, to the general disease, the " morbus 
localis primarius." 

It is true that this primary local affection does not, 
under the order Febres, show itself in the form of real 
pain. It does not on that account, however, the less 
certainly exist; although, to common apprehension, it 
may be the more difficult to prove its existence. It is 
an irritative, not a sensative affection, and has, as we 
believe, its seat in the stomach. Hence arises the dif- 
ficulty of proving it to be a reality. 

We have, however, in sundry instances, conclusive 
evidence of the existence of such an affection, and, 
therefore, very strong ground to infer its existence in 
cases where it is not so palpable to sense. 

In the kine pox and the inoculated small pox, the 
affection of the arm is purely irritative. It produces 
no pain. Were it situated on some internal part, re- 
mote from sight — the stomach, for example — we should 
have no evidence, except its effects, to convince us of 
its existence. Yet does it possess a sufficiency of force 
to excite in the system a general commotion — to pro- 
duce a fever on principles of sympathy. 

The same thing may be said in relation to the topical 
injury in cases of tetanus, arising from a punctured 
wound. The affection is altogether irritative. Being 
unaccompanied with pain, it is oftentimes forgotten 
even by the patient himself, before the general disease 
makes its appearance. Were it an internal affection 
its existence would never be suspected. 

Hydrophobia, from the bite of a rabid animal, affords 
another example of an affection entirely irritative. The 
wound heals, gives no pain, and is forgotten. But a 
secret irritation lingers in the spot, which, in a short 
period, produces, by sympathy, a fatal malady. 

In the diseases of children arising from dentition, in 
epilepsy, and many other complaints which we cannot 



64 PRELIMINARY DISCOURSE. 

now enumerate, the local affection is, in like manner, 
irritative. It excites no pain or strong sensation, to 
give notice of its presence Yet would it be errone- 
ous to apply to these diseases, the terms "sin mo.oo 
locali primario." 

Although the fact is not necessarily con ecte 1 h 
the present discussion, we shall, never heless, observe, 
that a mere irritative local affection is not only a reality, 
but more formidable, perhaps, as a source of general 
disease, than an affection which is sensative. 

Another ground of argument against the correctness 
of Dr. Cullen's definition is, that all febrile affections 
which we are capable of clearly tracing to their com- 
mencement, most certainly originate in a topical affec- 
tion. 

Thus, some arise from wounds, and are termed 
symptomatic; others from severe blows, sprains, or the 
fractures of bones, all of which are in their nature local; 
others from a debauch, or from improper articles of ali- 
ment, which excite a local affection of the stomach; 
others from the swallowing of poison, which evidently 
operates in the same way; and others, again, from a long 
continued exposure of a part of the body to dampness 
or cold. In this latter case, as in all the former, the 
part exposed being first affected with a local complaint, 
disorders the system through the medium of sympathy. 

It is impossible for any febrile cause, with which we 
are acquainted, to gain access to the whole system at 
once. It must first, therefore, attack locally, and after- 
wards extend its ravages on sympathetic principles. 

Such are our reasons, in part, for excepting to Dr. 
Cullen's definition of his order Febres. Although, in 
these diseases, the primary local affection does not very 
strongly manifest itself, we feel, notwithstanding, a con- 
viction that it exists. It is obvious to our reason, al- 
though not to our senses. Wrong, therefore, as it 



PRELIMINARY DISCOURSE. 65 

might, perhaps, have been for Dr. Cullen to have em- 
braced it in his definition, we deem a denial of its exist- 
ence much more exceptionable. A qualified admission 
of it would have been most consistent with the princi- 
ples of correct pathology. The order might have been 
characterized in the following terms: 

Proegressis languore, lassitudine, et aliis debilitatis 
sign is, pyrexia sine morbo locali primario maxime 
evidente. 

We think Dr. Cullen wrong in representing conta- 
gion as an essential characteristic of the Typhus and Sy- 
nochus fevers. The contagious nature of these dis- 
eases, in the United States, is extremely questionable. 
We are inclined to believe that the general amount 
of medical testimony, as derived from experience and 
observation, is against it. Our own opinion, delibe- 
rately formed from these sources, is unfavourable to the 
doctrine. 

By contagion we mean a specific poison — for if it be 
not specific it is not contagion, in as much as it is inca- 
pable of self-propagation — generated in the animal sys- 
tem by morbid action. In other words, we understand 
by it, a secreted morbific matter, the offspring of a pecu- 
liar diseased action, and capable of exciting action pre- 
cisely similar, which will again produce a poison of the 
same kind. From such a matter we have no reason to 
believe that Typhus and Synochus fevers arise. We 
are much more inclined to regard them as the offspring 
of a poison resulting from putrefaction. In the Uniled 
States, cleanliness and free ventilation prevent them 
from spreading. But such measures will not prevent 
the spreading of diseases that are truly contagious. 
Their insufficiency to arrest the progress of small pox 
is known to every one who is acquainted with the sub- 
ject. 

VOL. I. I 



66 PRELIMINARY DISCOURSE. 

Under the genus Typhus, our author places the yel- 
low fever of the West Indies and the United States. In 
this he is mistaken. Yellow fever is a species or variety 
of bilious fever, not of typhus. We do not believe the 
yellow fever of the United States to be a contagious dis- 
ease, in as much as it will not spread beyond the limits 
of a vitiated atmosphere. As there exists in yellow 
fever an inflammation of the stomach, it belongs, per- 
haps, of right, to the order Phlegmasia?. 

As our nosologist appears to be himself sensible of 
his error in referring Hectic fever to the order Febres, 
sine morbo locali primario, it would be superfluous in 
us to dwell on that point. A local affection forms as 
essential a part of hectic fever, as it does of ophthalmia 
or hepatitis. The disease, therefore, belongs to the or- 
der Phlegmasia^. 

Under the order Exanthemata, Dr. Cullen includes 
several diseases, which, in their characters, do not cor- 
respond with his general definition. He represents this 
order to consist of " Morbi contagiosi, semel tantum in 
decursu vitee aliquem afficientes." Comprised under it 
we find, Erysipelas, Miliaria, Urticaria, Pemphigus, 
and Aptha, neither of which is ever known to be com- 
municated by contagion. But the error into which the 
professor has fallen does not terminate here. Of erysi- 
pelas and urticaria certainly, and, we believe of pem- 
phigus also, the same individual is liable to repeated 
attacks. Instances are not wanting in which erysipelas 
is even remarkable for the frequency of its recurrence. 
Pestis, or true plague, respecting the contagious na- 
ture ofw r hich we shall speak hereafter, does not belong 
to the order Exanthemata. Its whole history convinces 
us that its proper place is under that of Febres — or, 
perhaps, of Phlegmasia. Its most natural and striking 
affinities are to typhus, or malignant bilious fever. 



PRELIMINARY DISCOURSE. 67 

There exists strong presumptive evidence that it is the 
same disease with the yellow fever of the United States, 
modified by climate, and, perhaps, other causes. 

Under the order Hemorrhagiae, Dr. Cullen places 
Phthisis Pulmonalis. 

This arrangement is injudicious. Haemoptysis is only 
an accidental symptom of pulmonary consumption. The 
complaint, consisting of fever connected with an inflam- 
matory topical affection, belongs, of right, to the order 
Phlegmasiae. 

From the manner in which Dr. Cullen has filled it 
up, the order Proflnvia ought to be abolished. 

He has included under it but two genera, catarrh and 
dysentery. Every symptom and character of these dis- 
eases declare them to belong to the order Phlegmasiae. 
Like phthisis pulmonalis, they consist of fever and a 
topical affection, which is always inflammatory. Their 
affinity to the Phlegmasiae are, therefore, natural and 
strong. 

If the order Profluvia be retained at all, with much 
more propriety might it be made to include, diarrhoea, 
diabetes, fluor albus, and, perhaps, pyrosis. Although 
these complaints consist also, in part, of a topical affec- 
tion, it is not always of an inflammatory character. 

The definition bestowed by Dr. Cullen on his class 
Neuroses, appears to be, in no small degree, faulty, in 
representing the diseases which it embraces as being 
"sine morbo locali" free from any topical affection. 

Apoplexy and palsy are its two only genera, in both 
of which there exists a local disease — of the stomach, 
perhaps, in the first instance, and of the brain, by 
sympathy. It is to relieve the latter that we bleed, 
and the former that we purge so copiously in this com- 
plaint. 

Our author has committed another error in consider- 



68 PRELIMINARY DISCOURSE. 

ing hydrocephalus internus as a species of apoplexy. 
According to his own definition of it, it evidently be- 
longs to the order Phlegmasiae. The affection of the 
head is inflammatory, and the disease is marked, in its 
early stage, always with considerable, and sometimes 
with violent fever. 

The disease of hydrophobia has been very rarely an 
object of our attention. We have seen enough of it, 
however, to be convinced, that it is not essentially a 
spasmodic affection. Even Dr. CuhWs own definition 
leads us, of necessity, to this conclusion. The spasm is 
nothing but an accidental symptom, although its occur- 
rence in the disease must be acknowledged to be very 
frequent. 

When we take into consideration the entire history of 
hydrophobia, we have no hesitation in referring it to 
the class Pyrexia; for it is certainly marked by febrile 
heat. Of this class it has, perhaps, the strongest affi- 
nity to the order Phlegmasia?. 

To the class Pyrexia, and order Phlegmasiae, ought 
the tabes purulenta of Dr. Cullen to be referred, instead 
of being placed, as it is by that writer, under the class 
Cachexias, and order Marcores. It consists in a topical 
inflammatory affection accompanying a fever. 

Under the class Cachexias and order Intumescen- 
tias, has our author thought proper to arrange hydro- 
thorax. 

In this again he does not appear to be altogether 
eorrect. Hydrothorax, oftentimes, at least, if not ge- 
nerally, commences as an inflammatory affection. It 
is one of the modes of termination of long continued 
peripneumony, asthma, catarrh, and other inflamma- 
tory complaints of the thorax, when they frequently 
occur. It is, in fact, the result of chronic inliamnia- 



PRELIMINARY DISCOURSE. $9 

tion. We are inclined to believe that its most natural 
affinities are to the diseases belonging to the order 
Phlegmasise. 

As Dr. Cullen's " First Lines of the Practice of Phy- 
sic" do not embrace his class Locales, the last in his 
system of Methodical Nosology, we shall decline, for 
the present, making any remarks on that extensive fa- 
mily of diseases. 



TABULAR VIEW 



OF 



CULLEN'S SYNOPSIS. 



AS we think it highly important for young gentle- 
men to be accustomed, from the commencement of 
their medical studies, to look at diseases through the 
medium of system; and as this can be done with most 
facility and advantage, when the view is exhibited in 
a compressed form, and fairly addressed to the sense of 
vision ; we have resolved to lay before our readers a 
tabular representation of Cullen's Synopsis of Methodi- 
cal Nosology, exhibiting diseases systematically ar- 
ranged into classes, orders, and genera; with an ex- 
planation of the terms, and the original words from 
which they are derived. 

CLASS I. 

PYREXIA, {Febrile Diseases) from srvp, fire, and ff<s, a habit. 

ORDER I.* 
Febres — Fevers. 

section I. 

Intermittentes (Intermittents.) 
Genus 1. Tertiana ( Tertian). 

2. Quartana {Quartan). 

3. Quotidiana ( Quotidian). 

[* We think Dr. Cullen mistaken in representing this order of 
diseases as exempt 1'roin any primary topical affection.— j£rf.] 



72 TABULAR VIEW, 

SECTION II. 

Continuae (Continued). 
Genus 4. Synocha, (Simfile Inflammatory Fever) from a-v\)£%v, to 
z continue. 
5. Typhus, (Nervous Fever) from rupej, stupor.f 

Mitior, (Mild).\ 

. — Gravior, (Malignant).^ 

i Icterodes, ( Yellow Fever) from iKre^og, jaun- 



dice, t 
[t These diseases are not contagious. The last should be 
under the order Phlegmasiae. — Ed.~] 
Genus 6. Synochus, from (rwex,u, to continue. 

Hectica, (Hectic Fever) — [This should stand under 
the order Phlegmasiae. — Ed.'} 

ORDER II. 

Phlegmasia, (Inflammations) from <p*.eyv, to burn. 
Genus 7. Phlogosis, ( Phlegmonous Inflammation). 

Apostema, (Abscess) from *#•<>, from, and ttrre^i, to 

stand. 
Gangraena, (Gangrene,) from yccyygcciv*, from ygxa, to 

eat up, or consume. 
Sphacelus, from <r<pot.x.etos, from c-0«tt«, to kill. 

8. Ophthalmia, (Inflammation of the Eye) from o$6uXim<;. 

9. Phrenitis, (Inflammation of the Brain) from (ppentrn, a 

frenzy. 

10. Cynanche, (Inflammation of the Throat) from xtwv, a 

dog, and «v^«, to strangle. 

. Tonsillaris, (of the Tonsils). 

Maligna, (Malignant). 

' Trachealis, (Crou/i). 

Pharyngaea, (of the Pharynx) from <pupwy%, 

the upper part of the oesophagus. 

11. Pneumonia, (Inflammation of the Thorax) from wiv/mii, 

the lungs. 
. Peripneumony, from nigi and mtv^m. 

Notha, (Bastard Perifineumony). 

Pleuritis,(.P/ezm'si/)from nXevpx, the mem- 
brane lining the lungs. 

■ Vomica (Abscess of the Lungs). 
————— Empyema, (Internal Abscess) from a, 
•within, and wnav, pus. 



TABULAR VIEW. 73 

Genus 12. Carditis, {Inflammation of the Heart) from x.*ehct, the 
heart. 

13. Peritonitis, (Inflammation of the Peritoneum) from 

zrsgiravuov, from ■sn^'.rtitu^ to stretch around. 

14. Gastritis, (Inflammation of the Stomach) from yxrvp, 

the stomach. 

15. Enteritis, (Inflammation of the Intestines) from evregov, 

an intestine. 

16. Hepatitis, (Inflammation of the Liver) from «j5r«f, the 

liver. 

Acuta, (Acute). 

Chronica, (Chronic). 

17. Splenitis, (Inflammation of the Sfileen) from s-ttAjjv, the 

spleen. 

18. Nephritis, (Inflammation of the Kidneys) from H0pt>s, 

the kidney. 

19. Cystitis, (Inflammation of the Bladder) from *.v(ms, 

the bladder. 

20. Hysteritis, (Inflammation of the Uterus) from vo-regcc, 

the uterus. 

21. Rheumatismus, (Rheumatism) from fcvfixri^u, to be 

affected with defluctions. 
■ Acutus, (Acute). 

— — — — — — Arthrodynia, (Chronic Rheumatism) 

from «f 0f«v, a joint, and o^v^, pain. 

22. Odontalgia, ( Tooth-ach) or rather pain in the jaw from 

a carious tooth — from eJW«, a tooth, and «Ayes, pain. 

23. Podagra, (Gout) from ws?, the foot, and «yf#, a sei- 

zure. 

' Regular. 

■ Atonic. 

Retroceding. 

Wandering. 

24. Arthropuosis, (Abscess in a Joint) from utfgov, a joint, 

and mov, pus. 

ORDER III. 

Exanthemata, (Erufitive Diseases) from *f and <*v0es, a flower. 
Genus 25. Variola, (Small Pox). 

— — — Discreta, (Distinct) a mild disease. 

' Confluens (Confluent) a malignant disease. 
VOL. I. K 



74 TABULAR VIEW. 

Genus 25. Variola Variolae Vaccinae, (Kine Pox) from vacca, a 
cow. 
[This disease was not known to Dr. Cullen. — Ed.] 

26. Varicella {Chicken Pox) the diminutive of variola. 

27. Rubeola (Measles) from rubeo, to become red. 

28. Scarlatina, (Scarlet Fever). 

29. Pesus, (Plague),— [This belongs to the order Febres 

or Phlegmasiae. — Ed.] 

30. Erysipelas, (An Inflammation of the Skin). 

31. Miliaria, (Miliary Fever) so called from the cuticular 

eruptions resembling millet seed. 
32 Urticaria, (Nettle Rash) from urtica, a nettle. 

33. Pemphigus, (a Pustular Eruption) from nt /*■?!& a 

pustule. 

34. Aphtha, (the Thrush) from ct*r6cci. [Most of the dis- 

eases of this order are not contagious — Ed.] 

ORDER IV. 
Hemorrhagic, (S/iontaneous Effusions of Blood) from «<jwf- 
. £<*>£*>, to discharge blood — from eci^ec, blood, and 
pta>, to flow. 
Genus 35. Epistaxis, (Hemorrhagy from the Nose) from esnra^w, 
to drop from. 

36. Haemoptysis, (S/iitting of Blood) from «<f«t, blood, 

and w?tw, to spit. 

37. Phthisis, (Consum/ition) from $0<ff-<c, from QBea, to cor- 

rupt. [This belongs of right to the order Phleg- 
masiae. — Ed.] 

38. H3emorrhois,(P?7es) from *«/»«, blood, and />'«», to flow. 

39. Menorrhagia, (An Excessive Flux of the Menses) from 

(xkvix, the menses, and pyyvvKpi, to break out. 
Haematemasis, ( Vomiting of Blood) from «//*«, blood, 
and ifJLtu, to vomit. 

ORDER V. 

Profluvia, (Fluxes, with Fever) from firofluo, to overflow. 
Genus 40. Catarrhus (Catarrh) from Kxrctpfeu, to flow down. 

41. Dysenteria, (Dysentery) from <5a?,bad or difficult, and 
evTffoii, an intestine. — [Both the genera of this order 
are misplaced. They belong to the order Phleg- 
masiae. — Ed.] 

CLASS II. 
NEUROSES, (Nervous Diseases) from nvgov, a nerve. 



TABULAR VIEW. 75 

ORDER I. 

C omata, (Soporose Diseases) from ku(4m, a propensity to sleep. 
Genus 42. Apoplexia, (apoplexy) from etna and t^o-o-u, to strike 
down. 

Sanguinea, from blood. 

Serosa, from serum. 

Hydrocephalica, from water. — [This be- 
longs to the order Phlegmasia. — Ed.~\ 
43. Paralysis, (Palsy) from nctectXvu, to loose. 
Tremor, (Trembling').' 

ORDER II. 

Adynamic, (Want of Power) from a. privative, ^weepa, power. 
Genus 44 Syncope, (Fainting-) from «-t/v, and kok^u, to cut or strike 
down. 

45. Dyspepsia, (Indigestion) from «%?, bad, and Twrru, to 

concoct. i 

46. Hypochondriasis, (Hypochondriac Affections) from 

v7r«%o)ifytxxos, one who is hipped — from two, under, 
and ^avo^es, a cartilage — i. e. an affection of the liver, 
which is situated under the cartilages of the false 
ribs. 
47. Chlorosis, (Green Sickness) from %>Mgos, green. — [This 
disease is misplaced: it belongs either to Amenor- 
rhoea or to the order Profluvia. — Ed.] 

ORDER III. 

Spasmi, (Spasmodic Diseases) from o-sraw, to draw. 
Genus 48. Tetanus, (General Cramp) from reiva, to stretch. 

49. Convulsio.(Co?zx>w£s2Grc)from con vello, to pull or pluck. 

50. Chorea, (St. Vitus' s Dance) from x°? £iX i a dance. 

51. Raphania, (Raphany) — so called because supposed to 

be produced by the seeds of the raphanus raphanis- 
trum. 

52. Epilepsia, (Epilepsy) from tfn and Xoc^ettvu, to seize 3 

because it attacks or seizes suddenly. 

53. Palpitatio, (Palpitation, or violent and irregular beat- 

ing of the heart). 

54. Asthma, (Asthma) from ess-fytot^y, to breathe with diffi- 

culty. 

55. Dyspnoea, (A Difficulty of Breathing) from ©V, bad, 

and 5Tve», to breathe. 



76 TABULAR VIEW 

Genus 56. Pertussis, (Hooping Co ugh ) from per, x\\uc\\,M\<\tussis, 
a cough. 

57. Pyrosis, ( Water Brash) from Trvgatrts, a burning. 

58. Colica, (Colic) from *oA«v, the largest of the intestines. 

59. Cholera, ( Vomiting and Purging) from %oM, bilc > an(1 

peu, to flow . 

60. Diarrhoea, (Purging) from <^«, through, and peu, to flow. 

— [This and Cholera belong more properly to the 
order Profluvia. — Ed.~] 

61. Diabetes, (An Excessive Discharge of Urine) from <5W, 

through, and fixtva, to pass. [This would seem also 
to belong to the order Profluvia. — EdJ] 

62. Hysteria, (Hysteric Disease) from veepec, the womb. 

63. Hydrophobia, (Canine Madness) from v$ca% , water, and 

AoZeu, to fear. 

ORDER IV. 

VesanIjE, (Menial Diseases) from vesania, madness. 
Genus 64. Amentia, (Idiotism) from <*, privative, and r*m, the mind. 
65. Melancholia, (Melancholy) from fteA*?, black, and #<>A>?, 
bile ; because supposed to arise from a vitiated con- 
dition of the bile. 
66 Mania, (Madness) from f^tivo^xi, to rage. 
67. Oneirodynia, (Disturbed Sleep) from omgo<;, a dream, 
and aJW)?, pain. 

CLASS III. 
CACHEXIA, (Cachectic Diseases) from xcckos, bad, and e|<?> a 
habit. 

ORDER. I. 
Marcores,( Universal Emaciation). 
Genus 68. Tabes, (Consumption). 

Purulenta. — [This, and most of the subsequent 

ones, belong to the order Phlegmasia. — Ed.~] 

Renalis. 

Hepatica. 

- e Stomacho. 

e Pericardio. 

Catarrhalis. 

Scrophulosa. 

Rachitica. 

Venenata. 

69. Atrophia, (Atrophy) from a, priv. and rpo<p>i, nourishment. 



TABULAR VIEW. 77 

ORDER II. 

IntumescentijE, ( General Swellings). 

SECTION I. 

AdiposjE, (Consisting of Fat). 
Genus 70. Polysarcia, (Corpulency) from *reA«/s, much, and «■*$!, 
flesh. 

SECTION II. 

Flatuos^e, (Consisting of Wind). 

Genus 71. Pneumatosis, (An Air Swelling) from irnvpuxraTis, 

from 7rvev(A.a,, breath, from 9rve«, to breathe. 

72. Tympanites, (Tympany) from Tvpunrent^u, to soundlike 

a drum. 

73. Physometra, ( Tympany of the Womb). 

SECTION III. 

AquoSiE sive Hydropes, (Consisting of Water). 

Genus 74. Anasarca, (Dropsy of the Cellular Membrane) from 

«v«, along or through, and e-«f|, the flesh. 

75. Hydrocephalus, (Dropsy of the Head) from vfrag, wa- 

ter, and x.e<p*to, the head. 

76. Hydrorachitis, (a Watery Swelling) generally seated 

in the spinal marrow. 

77. Hydro thorax, (Dropsy of the Chest) from vfrug, water, 

and £»/>«f , the chest. 

78. Ascites, (Dropsy of the Belly) from ««-ko?, a sack. 

79. Hydrometra, (Dropsy of the Womb) from vS'ag, water, 

and iwrga, the womb. 

80. Hydrocele, (Dropsy of the Tunica Vaginalis Testis) 

from vfup, water, and kjj^uj, a swelling. 

81. Physconia, (Physcony) an intumescence of the abdo- 

men, from an enlargement of some of its contents. 

82. Rachitis, (Rickets) from £<*#/?, the spine of the back. 

ORDER III. 

Impetigines, (Cutaneous Diseases) from in, and petigo, a scab. 

Genus 83. Scrophula, (Scrofula, or King's Evil) from scrofula, a 

swine, that animal being subject to a similar disease. 

84. Syphilis, ( Venereal Disease) from c-^Aa?, filthy. 

85. Scorbutus, (Scurvy). 

86. Elephantiasis, (Leg swelled and Skin thickened like 

that of an Elephant) from sAep«s, an elephant. 



78 TABULAR VIEW. 

Genus 87. Framboesia, ( Yaws) from framboise, in French, a rasp- 
berry. 

88. Lepra, (Lefirosy) from Aezn«, a scale. 

89. Trichoma, (Plica Polonica,or Plaited Hair). 

90. Icterus, (Jaundice) from ucre^t, the jaundice. 

CLASS IV. 
LOCALES, (Local Diseases.) 

' ORDER I. 
Dysesthesia, (Diseases of the Senses) from S~vg, bad, and cti<r8t)rts f 

feeling. 
Genus 91. Caligo, (Im/iaired Vision,from an opacity in the coats 

or humours of the Rye.) 

92. Amaurosis, (Gutta Serena, or Loss of Vision without 

any Opacity) from etfMtvgws, obscurity. 

93. Dysopia, (Difficult Vision) from $vi, bad or difficult, 

and airs, an eye. 

94. Pseudoblepsis, (False Vision) from ^ivfos, false, and 

/3AeiT(W. to see. 

95. Dyseccea,(Z)ea/>zess)from JWe*o/« — from ^t/s, bad, and 

ccx.au, to hear. 

96. Paracusis, (Depraved Hearing) from -zrx^x, wrong, and 

cckxu, to hear. 

97. Anosmia, (Loss of Smell) from«, privative, and a^a, to 

smell. 

98. Agheustia, (Loss of Taste) from «, privative, and 

yenofcxi, to taste. 

99. Anaesthesia, (Loss of Touch) from x, privative, and 

uKrOqtrif, feeling. 

ORDER IT. 

DYHOKRxiM,(Depraved appetites) from <JVs, bad, and e£ff<s, appe- 
ar tite. 

SECTION I. 

Appetitus Erronei, (False Afifietites). 
Genus 100. Bulimia, (Canine or Inordinate Appetite) from j3*?,an 
ox, and Aifie<, hunger. 

101. Polydipsia, (Inordinate Thirst) from vaAv«, much, and 

hiro-is, thirst. 

102. Pica, (Vitiated Afip.etite). 

103. Satyriasis, (Inordinate Lust in Men) from o-xtv^ixth. 



TABULAR VIEW. 79 

Genus 104. Nymphomania,(iircordmate Lust in TVomen)from wfi- 
<P», a nymph, and /Minx, madness. 
105. Nostalgia, (Home Sickness). 

SECTION 11. 
Appetitus Deficientes, (Defective Appetites). 
Genus 106. Anorexia. (Loss of Appetite) from «, privative, and 
opffi«, appetite. 

107. Adypsia, ( Want of Thirst) from «, privative, and 

h-xo-ct, thirst. 

108. Anaphrodisia, (Impotence) from <*, priv. and *p§ec^?«*, 

venery. 

ORDER III. 

Dyscinesi^:, (Depraved or Impeded Motion) from <5"t>$, bad, and 

uvea, to move. 
Genus 109. Aphonia, (Loss of Voice) from <*, privative, and pavy, 

the voice. 

110. Mutitas (Dumbness). 

111. Paraphonia, (Harsh or Depraved Voice) from zr*f«, 

bad, and p«v», the voice. 

112. Psellismus, (Stammering). 

113. Strabismus, (Squinting) from «-£<*C<£«y, to squint. 

1 1 4. Dysphagia, (Impeded Deglutition) from JVs, and <p*ya, 

to eat. 

115. Contractura, (Contraction of the Joints). 

ORDER IV. 

ApocENOsES,(/rccrea.setf Discharges)hom ccx-oxmu, to move from. 
Genus 116. Profusio, (Passive Hamorrhagy). 

117. Ephidiosis, (Excessive and Morbid Sweating) from 

itptfyea, to sweat. 

118. Epiphora, (Profusion of Tears). 

119. Ptyalismus, (Profusion of Saliva) from <pto, to spit. 

120. Eneuresis, (Involuntary Discharge of Urine). 

121. Gonorrhoea, (a Preternatural Mucous or Puriforvi 

discharge from the Urethra in Males) from yon 
semen, and f e&», to flow. 

ORDER V. 

Epischesis, (Obstructions) from e-ri^co;^ a suppression or ob- 
struction. 
Genus 122. Obstipatio, (Costiveness) from obstifio, to stop up. 



80 TABULAR VIEW. 

Genus 123. Ischuria, {Suppression of Urine) from i<r%<->, to restrain, 
and «fev, urine. 

124. Dysuria, {Difficulty in Discharging Urine) from <JV«, 

difficult, and «fev, the urine. 

125. Dyspermatismus, {An Impeded Emission of Semen) 

from ^ and ^eg/ix, semen. 

126. Amenorrhea, {a Retention of the Menses) from*, 

priv. fMivtxtos, monthly, and fe», to flow. 

ORDER VI. 

Tumores, {Tumours) from tmmeo, to swell. 
Genus 127. Aneurisma, {Aneurism). 

128. Varix, {a Local Enlargement of a Vein). 

129. Ecchymoma, {a Tumour formed by the Effusion of 

Blood into the Cellular Membrane) from e|, xcv, to 
pour out, and ctip.it., blood. 

130. Schirrus, {An Indolent Swelling for the most part of 

a Gland). 

131. Cancer, {Cancer). 

132. Bubo, {a Swelling of a Conglobate Gland). 

133. Sarcoma, {a Fleshy Enlargement) irom o"«f|, flesh. 

134. Verruca, (a Wart). 

135. Ulavus,(a Corn). 

136. Lupia, {a soft moveable Tumour situated under the 

skin, usually in a tendinous fiart.) 

137. Ganglion, {a hard moveable Tumour resting on a 

tendon). 

138. Hydatis, {a Watery Tumour) from vfag, water. 

139. Hydarthrus, ( White Swelling of the Joint) from vty, 

water, and xgdgov, a joint. 
140 Exostosis, {An Enlargement of a Bone) from tg and 
«s"tov, a bune. 

ORDER VII. 

Ectopia {Displacements) from ef, from, and roTot, a place. 
Genus 141. Hernia, {Rupture or Displacement of Soft Parts). 

142. Prolapsus, {The Falling down of a Part) from pr» 

and labor, to fall down. 

143. Luxatio, {Displacement of a Bone). 

ORDER VIII. 

Dyalyses, {Division of Parts) from h», and Ava, to divide or 
separate. 



TABULAR VIEW. 81 

Genus 144. Vulnus, {a Wound) a recent division of a soft part, 
accompanied with a haemorrhag. . 

145. Ulcus, {An Ulcer) a division of a soft part, accompa- 

nied by a purulent or ichorous discharge. 

146. Herpes, {Tetters) from epiru, to creep. 

147. Tinea, ( Tetter among the Hair). 

148. Psora, {The Itch) from ?nr«£«, a scab. 

149. Fractura, {Division of a Bone) from frango, to break 

150. Caries, {Rottenness or Mortification of a Bone). 



VOL. I. 



FIRST LINES 



OF THE 



PRACTICE OF PHYSIC. 



INTRODUCTION. 



1. IN teaching the Practice of Physic, We endeavout 
to give instruction for discerning, distinguishing, pre- 
venting, and curing diseases, as they occur in particular 
persons.* 

* This article contains a very clear, sticcinct and comprehensive view of 
the intellectual operations and practical duties of the physician in his inter- 
course with diseases. His first business is to discern them — i. e. to ascertain 
their existence, by his knowledge of the .difference between the phenomena 
of health and those of disease. He must next distinguish between one dis- 
ease and another. By this operation of his mind he attains a knowledge of 
the nature and character of the existing disease, without which he would be 
utterly incompetent to its treatment. 

Were all diseases an unit, this process of discrimination would be wholly 
unnecessary — indeed the very attempt at it would be preposterous. In such 
a case, the instant the mere existence of disease was ascertained, the practi- 
tioner might commence his treatment without the least circumspection or 
choice as to the remedy to be employed. Were disease an unit, practice 
would be also an unit; and therefore one remedy would be just as suitable 
as a ther. If all diseases be the same, where is the necessity, or even the 
ground, for that vigilance of attention, which the late Dr. Rush so zealously 
and properly inculcated, to "the state of the system." In what but "the 
state of the system" does disease consist? - II all diseases be the same, there- 
fore, all " states" are also the same: and hence the act of discrimination as to 
disease is superfluous* 

In his attempts to prevent diseases, the physician reduces to practice his 
knowledge of the principles of prophy laxis, which is clearly his duty. Their 
treatment or cure constitutes his last practical process. To accomplish this,, 
*s he ought, cenb, cilb, et tutd, requires a happy combination of multifariour 



84- PRACTICE OF PHYSIC 

2. The art of discerning and distinguishing dis- 
eases, may be best attained by an accurate and complete 
observation of their phenomena, as these occur in con- 
course and in succession, and by constantly endeavour- 
ing to distinguish the peculiar and inseparable concur- 
rence of symptoms, to establish a Methodical Noso- 
logy, or an arrangement of diseases according to their 
genera and species, founded upon observation alone, 
abstracted from all reasoning. Such an arrangement 
I have attempted in another work, to which, in the 
course of the present, I shall frequently refer.* 

3. The prevention of diseases depends upon the 
knowledge of their remote causes; which is partly deli- 
vered in the general Pathology, and partly to be deli- 
vered in this treatise.f 

knowledge. He must be as thoroughly versed in the qualities and proper- 
ties, the preparation, composition, and administration of remedies, as he is in 
the nature, character, and variations of diseases. Hence a great physician, 
in the true sense of the word, is as seldom found as a great general. 

* We discern and distinguish diseases precisely as we do all other objects 
of nature ; by a strict attention to their external qualities. But the external 
or only perceptible qualities oT diseases, are their signs and symptoms. It 
is on these, therefore, that our attention must be fixed, if we wish to acquire 
a knowledge of their character. 

f In the language of the schools, the causes of disease are divided, first, 
into remote and proximate. The remote causes are again divided i»to pre- 
disposing and exciting or occasional. 

The remote predisposing cause is that, which, by its agency on the human 
body, produces in it a predisposition or strong liability to disease. The re- 
mote occasional cause is that, which, by its influence on the body, when thus 
predisposed, gives rise to actual disease. 

The predisposing cause of intermitting fever is marsh miasma; the occa- 
sional or exciting cause, exposure to a shower of rain or the night air, to 
cold or to excessive fatigue. 

The predisposing cause of influenza is an aerial poison, or something pe- 
culiarly deleterious in the condition of the atmosphere ; the exciting cause, 
the same as in the case of intermitting fever. 

Were occasional causes strictly avoided, the predisposing cause would be, 
in most instances, deprived of its power to injure. This, however, is not 
always the case. In some diseases the predisposing is also the occasional 
cause. This is certainly the case in small pox, kine pox, and, we believe, in 
every disease that is truly contagious. Contagion, in the strict sense of the 



PRACTICE OF PHYSIC. 85 

4. The cure of diseases is chiefly, and almost un- 
avoidably founded in the knowledge of their proximate 
causes. This requires an acquaintance with the insti- 
tutions of medicine; that is, the knowledge of the struc- 
ture, action, and functions of the human body; of the 
several changes which it may undergo; and of the 
several powers by which it can be changed. Our 
knowledge of these particulars, however, is still incom- 
plete, is in many respects doubtful, and has often been 
involved in mistake and error. The doctrine, there- 
fore, of proximate causes, founded upon that know- 
ledge, must be frequently precarious and uncertain. It 
is, however, possible for a judicious physician to avoid 
what is vulgarly called theory, that is, all reasoning 
founded upon hypothesis, and thereby many of the 
errors which have formerly taken place in the institu- 
tions of medicine. It is possible also for a person who 
has an extensive knowledge of the facts relative to the 
animal economy in health and sickness, by a cautious 
and complete induction, to establish many general prin- 
ciples which may guide his reasoning with safety; and 
while, at the same time, a physician admits as a founda- 
tion of practice those reasonings only which are simple. 

term, is a poison which gives rise to its specific effect, independently of 
every auxiliary cause. It both predisposes to and excites the disease it pro- 
duces. If it did not do this, it would cease to be a poison. 

The chief differences between contagion and other poisonous substances 
is, that the former acts without any nice dependence on dose or quantity — a 
small dose being as capable of doing mischief as a large one — and, that it is 
competent to the business of self-propagation, by exciting, in living matter, 
such a specific state of action as reproduces itself. It is possessed of a kind 
of generative power, which is not the case with any other poison. Although 
the morbid action produced by arsenic destroys life, it does not produce 
arsenic as one of its results. 

During the prevalence of an epidemic, which is but another name for a 
disease of atmospheric origin, every person is liable to an attack of it, be- 
cause he is under the influence of the remote predisposing cause. His only 
security, therefore, consists in a strict avoidance of exciting causes. 



86 PRACTICE OF PHYSIC. 

obvious, and certain, and for the most part admits as 
proximate causes those alone that are established as 
matters of fact rather than as deductions of reasonings 
he may, with great advantage, establish a system of 
practice chiefly founded on the doctrine of proximate 
causes. But when this cannot be done with sufficient 
certainty, the judicious and prudent physician will have 
recourse to experience alone; always, however, aware 
of the hitherto incomplete and fallacious state of em- 
piricism.* 

5. With a strict attention to these considerations in 
the whole of the following treatise, I proceed to treat 
of particular diseases in the order of my Methodical 
Nosology. 

* The proximate cause is the effect produced by means of the predispos- 
ing and exciting causes. It is, in other words, the morbid action in which 
the disease itself consists. This, therefore, did we in all cases possess a full 
and satisfactory knowledge of it, would constitute unquestionably the best 
foundation on which to erect our plan of cure. 

Had we unequivocal evidence that a certain disease consists in a spasm of 
a particular organ, and did we possess a remedy perfectly calculated to re- 
move that spasm, the exhibition of such remedy would constitute the fulfil- 
ment of the true and only indication. Did another disease consist, with 
certainty, in an excess of vascular action in a particular part, and were we 
in possession of a remedy or mode of practice precisely calculated to reduce 
that action, we could be at no loss as to the measures necessary to be pur- 
sued. Did a third disease consist in a defective action of the secretory ves- 
sels of the kidneys, and had we a remedy we could confidently rely on as a 
diuretic, the exhibition of that remedy should constitute our practice. This 
would be treating diseases in a manner truly rational and scientific — a man- 
ner that could not fail to add to the utility, as well as to the dignity and eleva- 
tion of our profession. 

But we have to regret that our knowledge of the human system, whether 
in health or disease, is not sufficient to warrant us in the attempt to prac- 
tise at all times on first principles. Although our acquaintance with the na- 
ture of diseases directs us, in part, in our mode of treating them, we must 
also, in part, rely on our experience. We apprehend that we are indebted 
more to the latter, and less to the former source, than Dr. Cullen seems -will- 
ing to allow 



PRACTICE OF PHYSIC. $7 



PAJRT I. 

OF PYREXIA, OR FEBRILE DISEASES. 

o*. PYREXIAE, or febrile diseases, are distinguished 
by the following appearances. After beginning with 
some degree of cold shivering, they show some increase 
of heat, and an increased frequency of pulse, with the 
interruption and disorder of several functions, particu- 
larly some diminution of strength in the animal func- 
tions* 

7. Of these Pyrexiae I have formed a class, and have 
subdivided it into five orders of fevers, inflammations, 
eruptions, hemorrhagies, and fluxes. — See Synop- 
sis Nosologias Methodicas, Edit 3. 1780. 



BOOK. I. 

OF FEVERS. 

CHAPTER I. 
OF THE PHENOMENA OF FEVERS. 

8. THOSE diseases are more strictly called fever*. 
which have the general symptom of Pyrexia, without 

* In his definition of pyrexiae or febrile diseases, our author makes use ofan 
expression which we think too strong. « After beginning with some degree 
of cold shivering," &c. 

That febrile diseases are ushered in by a sensation of coldness is true; 
but it is equally true, that this sensation does not, at all times, nor, perhaps, 
as a general rule, amount to a shivering. In many of the most violent and ma- 



88 PRACTICE OF PHYSIC. 

having along with them any topical affection that is 
essential and primary, such as the other orders of the 
Pyrexiae always have. 

9. Fevers, as differing in the number and variety of 
their symptoms, have been very properly considered as 
of distinct genera and species. But we suppose that 
there are certain circumstances in common to all the 
diseases comprehended under this order, which are 
therefore those essentially necessary to, and properly 
constituting the nature of fever. It is our business es- 
pecially, and in the first place, to investigate these ; and 
I expect to find them as they occur in the paroxysm, or 
fit, of an intermittent fever, as this is most commonly 
formed. 

10. The phenomena to be observed in such a pa- 
roxysm are the following. The person is affected, first, 
with a languor or sense of debility, a sluggishness in 
motion, and some uneasiness in exerting it, with fre- 
quent yawning and stretching. At the same time, the 
face and extremities become pale; the features shrink; 
the bulk of every external part is diminished; and the 
skin over the whole body appears constricted, as if 
cold had been applied to it. At the coming on of 
these symptoms, some coldness of the extremities, 
though little taken notice of by the patient, may be per- 

lignant cases of disease, the cold stage is so slight as to be scarcely percep- 
tible. 

Nor is it true that the pyrexia actually begin with a sensation of coldness. 
That symptom does not constitute the first link in the chain of disease. It 
is itself the effect of a preceding link, viz. the local irritation produced by 
the immediate agency of the febrile cause. In the whole of Dr. Cullen's 
order Febris, as well as in many other febrile complaints, we feel persuaded, 
as we have already observed, that the original topical affection takes place 
in the stomach. This constitutes the seat and centre of the disease ; whence, 
asfromapunctum saliens, or point of action, it extends by sympathy through- 
out the system. Hence the importance, especially in the early stage of 
these complaints, of directing 'iur attention to the state of the stomach This 
subject shall be resumed and more fullv considered on a subsequent occasion. 



PRACTICE OF PHYSIC. 89 

ceived by another person. At length, the patient him- 
self feels a sensation of cold, commonly first in his 
back; but, from thence, passing over the whole body; 
and now his skin feels warm to another person The 
patient's sense of cold increasing, produces a tremor in 
all his limbs, with frequent successions or rigours of 
the trunk of the body. When this sense of cold, and 
its effects, have continued for some time, they become 
less violent, and are alternated with warm flushings. By 
degrees, the cold goes off entirely; and a heat, greater 
than natural, prevails, and continues over the whole 
body. With this heat, the colour of the skin returns, 
and a preternatural redness appears, especially in the 
face. Whilst the heat and redness comes on, the skin 
is relaxed and smoothed, but for some time continues 
dry. The features of the face, and other parts of the 
body, recover their usual size, and become even more 
turbid. When the heat, redness, and turgescence have 
increased, and continued for some time, a moisture ap- 
pears upon the forehead, and by degrees becomes a 
sweat, which gradually extends downwards over the 
whole body. As this sweat continues to flow, the heat 
of the body abates; the sweat, after continuing some 
time, gradually ceases; the body returns to its usual 
temperature; and most of the functions are restored to 
their ordinary state.* 

11. This series of appearances gives occasion to di- 
vide the paroxysm into three different stages; which 
are called the cold, the hot, and the sweating 
stages, or Fits. 

In the course of these, considerable changes happen 

* It is but justice to Dr. Cullen to remark, that this and the following 
sections contain the most perfect picture of a paroxysm of intermitting 
fever that is any where to be found. Indeed, his descriptions of diseases, in 
general, are possessed of such accuracy and excellence, as to leave the 
practitioner but little to wish for on that subject. 
VOL. I. M 



90 PRACTICE OF PHYSIC. 

in the state of several other functions, which are now 
to be mentioned. 

12. Upon the first approach of languor, the pulse be- 
comes sometimes slower, and always weaker than be- 
fore. As the sense of cold comes on, the pulse becomes 
smaller, very frequent, and often irregular. As the cold 
abates and the heat comes on, the pulse becomes more 
regular, hard, and full; and in these respects, increases 
till the sweat breaks out. As the sweat flows, the pulse 
becomes softer, and less frequent, till the sweat ceasing 
altogether, it returns to its usual state. 

13. The respiration also suffers some changes. During 
the cold stage, the respiration is small, frequent and 
anxious, and is sometimes attended w:ith a cough: as 
the hot stage comes on, the respiration becomes fuller 
and more free; but continues still frequent and anxious, 
till the flowing of the sweat relieves the anxiety, and 
renders the breathing less frequent and more free. With 
the ceasing of the sweat, the breathing returns to its 
ordinary state.* 

. * In respiration the patient experiences a kind of asthmatic stricture and 
anxiety. This no doubt arises from a direct sympathy between the sto- 
mach and lungs, which is oftentimes, at least, if not generally, the source 
of real asthfpa. Hence, in that disease, the advantages derived from eme- 
tics and other remedies that operate on the stomach. A dose of tartar eme- 
tic has sometimes prevented a paroxysm of asthma, when exhibited as soon 
as the threatenings were felt. 

During the cold stage of an intermittent, there appears to exist on the 
surface of the lungs a real spasm, at least a want of healthy action, in con- 
sequence of which that organ is disqualified for the performance of its 
duty in relation to the blood. 

This spasm or stricture, prevailing also in the mouth, on the tongue, and 
in the fauces, and preventing secretion there, appears to be the cause of 
the troublesome thirst that is felt. It relaxes only with the relaxation of 
that on the surface of the body, which is manifested by the free and copi- 
ous flowing of the sweat. On the occurrence of this, the thirst and diffi- 
culty of respiration cease. 

The process of puking, whether it arise spontaneously or be produced by 
art, is known to operate favourably in exciting a sweat, and in relieving thirst 
and anxious respiration. This shows, we think, with sufficient clearness, 



PRACTICE OF PHYTIC. 9] 

14. The natural functions also suffer a change. Upon 
the approach of the cold state, the appetite for food 
ceases, and does not return till the paroxysm be over, 
or the sweat has flowed for some time. Generally 
during the whole of the paroxysm, there is not only a 
want of appetite, but an aversion from all solid, and es- 
pecially animal food. As the cold stage advances, there 
frequently comes on a sickness and nausea, which often 
increase to a vomiting of a matter that is for the most 
part bilious. This vomiting commonly puts an end to 
the cold stage, and brings on the hot. As the hot stage 
advances, the nausea and vomiting abate; and when the 
sweat breaks out, they generally cease altogether. 

15. A considerable degree of thirst is commonly felt 
during the whole course of the paroxysm. During the 
cold stage, the thirst seems to arise from the dryness 
and clamminess of the mouth and fauces, but during 
the hot stage, from the heat which then prevails over 
the whole body; and as the sweat flows, the mouth be- 
comes moister, and the thirst, together with the heat, 
gradually abates. 

16. In the course of a paroxysm, there is often a 
considerable change in the state of the secretions. The 
circumstances just now mentioned, show it in the se- 

that these symptoms arise from the same cause, and that they are closely 
associated with the state of the stomach. 

On these points, the explanation we attempt is somewhat different from 
that of Dr. Cullen. The reader is at liberty to choose between us. 

Under the present head we shall only further observe, that the limpid 
state of the urine, the drying up of ulcers on the surface of the body, and 
the detumescence of tumours, are. in our estimation, most easily and satis- 
factorily explained, by admitting the existence and action of spasm By this 
term we mean a morbid contraction produced by immediate or sympathetic 
irritation. 

It is owing, perhaps, to the operation of the same cause, that a mercurial 
salivation is suspended during a paroxysm of intermittent, but recurs on the 
return of a state of pyrexia. This, although not a very frequent, is a well 
known phenomenon. 



92 PRACTICE OF PHYSIC. 

cretion of the saliva ami mucus of the mouth; and it is 
still more remarkable with respect to the urine. During 
the cold stage, the urine is almost colourless, and with- 
out cloud or sediment. In the hot stage it becomes 
high coloured, but is still without sediment. After the 
sweat has flowed freely, the urine deposits a sediment, 
commonly lateritious, and continues to do so for some 
time after the paroxysm is over. 

17. Excepting in certain uncommon cases which are 
attended throughout with a diarrhoea, stools seldom oc- 
cur till towards the end of a paroxysm, when commonly 
a stool happens, which is generally of a loose kind. 

18. Analogous to these changes in the state of the 
secretions, it frequently happens that tumours subsist- 
ing on the surface of the body, suffer, during the cold 
stage of fevers, a sudden and considerable detume- 
scence; but generally, though not always, the tumours 
return to their former size during the sweating stage. 
In like manner, ulcers are sometimes dried up during 
the cold stage; and return again to discharge matter 
during the sweating stage, or after the paroxysm is 
over. 

19. Certain changes appear also in sensation and 
thought. During the cold stage, the sensibility is often 
greatly impaired; but when the hot stage is formed, 
the sensibility is recovered, and often considerably in- 
creased. 

20. With respect to the intellectual functions, when 
the cold stage comes on, attention and recollection be- 
come difficult, and continue more or less so during the 
whole paroxysm. Hence some confusion of thought 
takes place, and often arises to a delirium, which some- 
times comes on at the beginning of the cold stage, but 
more frequently not till the hot stage be formed. 

21. It belongs also to this place to remark, that the 



PRACTICE OF PHYSIC. 93 

cold stage sometimes comes on with a drowsiness and 
stupor, which often increase to a degree that may be 
called comatose, or apoplectic* 

22. We have still to add, that sometimes, early in the 
cold stage, a headach comes on; but which, more com- 
monly, is not felt till the hot stage be formed, and then 
is usuall) attended with a throbbing of the temples. The 
headach continues till the sweat breaks out; but as this 
flows more freely, that gradually goes off. At the same 
time with the headach, there are commonly pains of 
the back, and of some of the great joints; and these 
pains have the same course with the headach. 

23. These are nearly the whole, and are at least the 
chief of the phenomena which more constantly appear 
in the paroxysm of an intermittent fever; and we have 
pointed out their ordinary concourse and succession. 
With respect to the whole of them, however, it is to be 
observed, that in different cases, the several phenomena 
are in different degrees; that the series of them is more 
or less complete; and that the several parts or stages in 
the time they occupy, are in a different proportion to 
one another. 

24. It is very seldom that a fever consists of a sin- 
gle paroxysm, such as we have now described; and it 
more generally happens, after a certain length of time 
has elapsed from the ceasing of the paroxysm, that the 
same series of phenomena again arises, and observes 
the same course as before; and these states of fever 
and apyrexia often continue to alternate with one 
another for many times. In such cases, the length of 
time from the end of one paroxysm to the beginning of 

* The comatose state spoken of in this section is much relieved, if not 
effectually removed, by the exhibition of an emetic. It arises from sympa- 
thy between the stomach and brain. In some cases of it blood-letting be- 
comes necessary. 



94 PRACTICE OF PHYSIC. 

another, is called an intermission; and the length of 
time from the beginning of one paroxysm to the begin- 
ning of another next succeeding, is called an interval. 
25. When the disease consists of a number of pa- 
roxysms, it is generally to be observed, that the inter- 
vals between them are nearly equal; but these inter- 
vals are of different lengths in different cases. The 
most usual interval is that of forty-eight hours, which 
is named the tertian period. The next most com- 
mon is that of seventy-two hours, and is named the 
quartan period. Some other intervals are also ob- 
served, particularly one of twenty-four hours, named 
therefore, the quotidian; and the appearance of this 
is pretty frequent. But all other intervals longer than 
that of the quartan are extremely rare, and probably 
are only irregularities of the tertian or quartan pe- 
riods* 

* We have some doubts as to the correctness of a part of this article, par- 
ticularly as applied lo the United States. If we be permitted to rely on our 
own observation, we must believe, that, instead of being a more frequent, 
the quartan ague is a less frequent form of the disease than the quotidian. 
In the southern stales, quotidian intermittent* are often seen, quartans more 
rarely ; and much more rarely still does the disease assume the quartan form 
at its commencement. Quartans are more frequently formed out of ter- 
tians and quotidians, when unusually protracted. 

Of tertian and quartan intermittents there are several varieties. The fol- 
lowing may be enumerated as of the most frequent occurrence. The dou- 
ble tertian, having a paroxysm everyday, with the alternate paroxysms 
alike. The double tertian, with two paroxysms every other day. The triple 
tertun, with two paroxysms on one day, and one on the next. The double 
quartan, with two paroxysms on the first day, none on the second and third, 
and 'wo again on the fourth. The double quartan, with a paroxysm on the 
first day, and another on the second, but none on the third. The triple 
quartan, with three paroxysms every fourth day. The triple quartan, with 
a paroxysm every day, every fourth paroxysm beng alike. 

Under our own observation all these varieties have never fallen : but they 
are familiarly mentioned in the writings of authors whose experience has 
been ample We are not, therefore, permitted to doubt of their existence. 

The most singular circumstance in the history of intermittents, and, in- 
deed, one of the most curious and inexplicable in any way connected with 
medical science, is the periodical character of those complaints. Why an 



PRACTICE OF PHYSIC. 95 

26. The paroxysms of pure intermittent fevers are 
always finished in less than twenty-four hours: and 

irritation so severe as to have produced the most violent and distressing- 
fever, should become perfectly dormant, and having remained so for '.he 
space of twelve, thirty-six, or sixty-two hours, recur in all its original 
strength, to pursue again the same course? and why this order of things 
should continue for months, and even years ? are questions which have 
never been satisfactorily answered. 

It has, indeed, been said, and may be, perhaps, again, that the excitability 
of the part immediately acted on by the morbific cause, having become ex- 
hausted by the violence of impression, requires, for its restoration, the 
lapse of a definite period; and that this restoration is no sooner effected, 
than the original cause, acting again, reproduces its original train of phe- 
nomena. But this position, admitting it to be true, is nothing but a simple 
statement of a fact, instead of an assignment of an efficient cause. Far from 
affording an explanation, therefore, it is itself a subject difficult to be ex- 
plained. 

Some writers, in their attempts to solve the problem of the periodical na- 
ture of the intermittent, have added to the supposed effect of exhausted 
and renovated excitability, the influence of the solar or lunar day. Oihers, 
the influence of the earth revolving on its own axis, connected with that of 
electricity and gravitation, as being uniformly the same at given hours, and' 
calculated, therefore, for the production of the same effect. Others again 
have attributed the phenomena to the force of habit, and the identity of 
impression produced by an identity of causes in us and around us at given 
hours. In the wildness and multifarious resources of conjecture, still fur- 
ther hypotheses have been attempted on this subject, the very recital of 
which we should deem an inadmissible consumption of time. 

In the present state of medical science, we are apprehensive that all we 
can honestly do is, to assume the periodical nature of intermittents as an 
ultimate fact, and refer it to a law of our nature not yet explained. We are 
the more strongly inclined to this opinion, in consideration of the periodi- 
cal character of many other complaints besides intermittents. 

Insanity and epilepsy are periodical diseases : so, in like manner, are 
asthma and gout. In tetanus, the muscular spasms intermit and recur, with- 
out any apparent cause for such changes. So do the pains of colic, the 
gripings in diarrhoea, the tormina of dysentery, and the throes of parturi- 
ency. In these cases, more especially in tetanus, colic and the parturient 
process, the presence of the irritating cause is uniform, while its effects are 
intermitting. In them therefore, no less than intermittents, the suspension 
of the irritation takes place under the influence of the irritating cause. 
These, with many other kindred facts, we are forced to refer to the same 
original law of our nature from which we would derive the phenomena of 
intermittents. They are inexplicable, at present ; although a single disco- 
very may fortunately hereafter explain them all. 

To the same law do we appear to be indebted for many of the most fami- 
liar phenomena of health. Of these we might mention, in particular, the 



96 PRACTICE OF PHYSIC. 

though it happens that there are fevers which consist of 
repeated paroxysms, without any entire intermission 
between them; yet in such cases it is observed, that 
though the hot "and sweating stages of the paroxism 
do not entirely cease before the twenty-four hours from 
their beginning have expired, they suffer, however, be- 
fore that time, a considerable abatement or remission 
of their violence; and at the return of the quotidian 
period, a paroxysm is in some shape renewed, which 
runs the same course as before. This constitutes what 
is called a remittent fever 

21. When in these remittents the remission is consi- 
derable, and the return of a new paroxysm is distinctly 
marked by the symptoms of a cold stage at the begin- 
ning of it; such fevers retain strictly the appellation of 
remittents. But when it happens, as it does in cer- 
tain cases, that the remission is not considerable, is per- 
haps without sweat, and that the returning paroxjsm 
is not marked by the most usual symptoms of a cold 
stage, but chiefly by the aggravation or exacerbation 
of a hot stage, the disease is called a continued fever. 

28. In some cases of continued fever, the remissions 
and exacerbations are so inconsiderable as not to be 
easily observed or distinguished; and this has led phy- 
sicians to imagine, that there is a species of fever sub- 
sisting for several days together, and seemingly, con- 
sisting of one paroxysm only. This they have called a 
continent fever; but, in a long course of practice, I 
have not had an opportunity of observing such a fever. 

29. It is, however, to be observed here, that the 
fevers of a continued form are to be distinguished from 

recurrence, at stated periods, of the appetites of hunger and thirst, the 
call to evacuate the urine and faeces, the disposition to sleep and awake, 
with such other actions and states of the system as are under the influence 
of habit. 



PRACTICE OF PHYSIC. 97 

one another; and that, while some of a very continued 
form do still belong to the section of intermittents, there 
are others which, though still consisting of separate 
and repeated paroxysms, yet as different from their 
causes and circumstances from intermittents, are to be 
distinguished from the whole of these, and are more 
strictly to be called and considered as continued. 
Such are most of those which have been commonly 
supposed to be continent; and those which by moat) 
writers have been simply named continued; and wtticli 
term I have employed as the title of a section, to be' 
distinguished from that of intermittent. 

I shall here add the marks by which, in practice, 
these different continued fevers may be distinguished 
from one another. 

Those fevers of a continued form, which, however, 
still belong to the section of Intermittents, may be dis- 
tinguished by their having passed from an intermittent 
or remittent form, to that of a continued; by their 
showing some tendency to become intermittent, or at 
least remittent; by their being known to have been 
occasioned by marsh miasmata; and, for the most part, 
by their having but one paroxysm, or exacerbation and 
remission, in the course of twenty-four hours. 

On the other hand, Continued Fevers, to be more 
strictly so called, may be distinguished by their show- 
ing little tendency to become intermittent or remittent 
in any part of their course, and especially after the 
first week of their continuance; by their being occasion- 
ed by human contagion, at least by other causes than 
the marsh miasmata; and by their having pretty con- 
stantly an exacerbation and remission twice in the 
course of twenty-four hours. In both cases, the know- 
ledge of the nature of the epidemic for the time pre- 

VOL. I. N 



98 PRACTICE OF PHYSIC. 

vailing, may have a great share in determining the na- 
ture of the particular fever. 

30. With respect to the form, or type of fevers, this 
further may be observed, That the quartan, while it has 
the longest interval, has. at the same time, the longest 
and most violent cold stage; but, upon the whole, the 
shortest paroxysm: That the tertian, having a shorter 
interval than the quartan, has, at the same time, a short- 
er and less violent cold stage; but a longer paroxysm: 
And lastly, that the quotidian, with the shortest inter- 
val, has the least of a cold stage; but the longest pa- 
roxysm. 

31. The type of fevers is sometimes changed in their 
course. When this happens, it is generally in the fol- 
lowing manner: Both tertians and quartans change into 
quotidians, quotidians into remittents, and these last be- 
come often of the most continued kind. In all these 
cases, the fever has its paroxysm protracted longer 
than usual, before it changes into a type of more fre- 
quent repetition. 

32. From all this a presumption arises, that every 
fever consists of repeated paroxysms, differing from 
others chiefly in the circumstances and repetition of the 
paroxysms; and therefore, that it was allowable for us 
to take the paroxysm of a pure intermittent as an ex- 
ample and model of the whole, 



PRACTICE OF PHYSIC. 99 

CHAPTER II* 

OF THE PROXIMATE CAUSE OF FEVER. 

33. THE proximate cause of fever seems hitherto to 
have eluded the research of physicians; and I shall not 

* In this and the following chapter, which treats of the " difference of fe- 
vers and its causes," our author has placed before us as curious a specimen 
of the " frost-work of fancy" as is any where to be found in the records of 
medicine- He has, with great labour, and not a little ingenuity, piled one 
hypothesis on another, each alike incapable of supporting or being support- 
ed, until he has erected a monument of conjecture altogether commensurate 
with his own greatness. It is thus that illustrious men oftentimes distin- 
guish themselves not more by their virtues and excellencies, than by their 
errors and faults. 

In all our reading we do not recollect ever to have met with a more vi- 
.sionary production, or a more inconclusive attempt to give shape and stabi- 
lity to any opinion, than that of Dr Cullen to establish here his theory of 
fever. Throughout the whole course of his affected reasoning, there is 
nothing presented to us but one unqualified assumption after another, until, 
at the end, we find that every thing has been assumed and nothing confirm- 
ed — every thing asserted and nothing proved. The worst and most dan- 
gerous feature of the doctrine is, that there is thrown around it an air of 
plausibility and candour, exceedingly seductive of the youthful mind. In a 
man of years and experience, extensive learning and philosophical research, 
we deem it scarcely consistent with intellectual honesty and moral recti- 
tude, thus to palm on unsuspecting youth, and that portion of feeble minded 
adults, who read only to believe and adopt, a tissue of errors, in which it is 
almost impossible he could himself have believed — which he must, at least, 
have considered in the nature of postulata, that did not promise to be readily 
converted into demo> strated truths. 

Independently of the error which such hypothetical structures actually 
inculcate, they are, when reared by high authority, professional articles of 
pernicious tendency. Their example is contagious, and renders the pro- 
cess of fancying, instead of experimenting and observing, fashionable in medi- 
cine. They give sanction and encouragement to those indolent inquirers, 
whose practice it is to substitute conjecture for observation and speculation 
for research ; and thus become the cause of a wide spreading evil. 

Had we leisure to engage in it, a fair analysis of our author's theory 
would afford ample testimony that we do not speak of it in terms of exag- 
geration. H s atony and diminished enerq-y of the bruin, his sedative causes of 
fever, and all his operations of the vis medicatrix naturx, as he employs them^ 



100 PRACTICE OF PHYSIC. 

pretend to ascertain it in a manner that may remove 
every difficulty; but I shall endeavour to make an ap- 

would appear to be as absolute fictions as any thing that gives colouring to 
the pages of romance. 

We think there cannot be, in nature, a more preposterous hypothesis, 
than that which attributes to the influence of a sedative agent— if the expres- 
sion be, admissible— an augmentation of excitement in living matter— which 
derives an increase of action, whether healthy or diseased, from that which, 
in its nature, is acknowledged to be calculated only to diminish action; and 
which receives even its name from its supposed power to effect such dimi- 
nution. When medical writers shall have learnt to deal more in matter, 
and less in mere words, unsanctioned by reason, we feel persuaded that the 
term sedative will be erased from the nomenclature of materia medica. 
Strictly and philosophically speaking, we consider it as nothing but an 
empty sound. 

If the term, even in common acceptation, possess any meaning at all, a se- 
dative is that, which, by diminishing or removing existing impression, di- 
minishes or suspends existing action. If the impression be not removed, it 
is a law of nature that the action will continue. But how can a substance or 
agent remove from living matter an impression already in existence, or sus- 
pend or alter action already going forward, otherwise than by substituting 
an impression and a mode of action of its own ? Such a process is impossi- 
ble A stimulant impression inducing action is a reality, and cannot be re- 
moved or in any way affected by that which is not a reality. If a reputed 
sedative be a reality, it must, when applied to living matter, act ; and if 
it act, it must make an impression : this very action and impression, there- 
fore, pronounce it to be a sedative only in name, not in fact : to be capable 
of acting and impressing, it must be a stimulant ; impression being nothing 
but another name for stimulating action. • 

For the more clear and satisfactory illustration of our subject, we shall in- 
stitute a comparison with certain phenomena in nature which are perfectly 
understood. Living action, the result of stimulation, may be aptly enough 
compared to a stream of water, or a moving body : it possesses a degree of 
impetus or force. To arrest or alter the course of a flowing stream or a 
bodv in motion, force must be opposed to it. A mere negative oppos tion, 
i. e. opposition without force, will be found insufficient. Such precisely is 
the case in relation to living action. It is sent forward by one impression, 
and can be stopt or altered only by another. A substance incapable of mak- 
ing an impression cannot effect it. 

Again : the Will is put in action only by motive, and nothing but another 
motive can alter or suspend its action. That which is incapable of acing 
as a motive — being to it a nonentity — can have no influence on it. The 
same thing is true of animal action arising from stimulus: nothing short 
of stimulus can slop it. That which has no stimulating power stands in the 
same relation to it as if it had no existence. But in a case that is so plain, 
we deem it superfluous to multiply words. To attribute to reputed sedatives 
♦he power of altering vital action in any other way than by means of iin- 



PRACTICE OF PHYSIC. 101 

proach towards it, and such as, I hope, may be of use 
in conducting the practice in this disease: while at the 



pression, would be to assert the existence of an effect without a cause. In 
the strict sense of the term, a sedative is known only in the language of the 
schools. 

To remove as far as practicable every difficulty and objection that might 
be thrown in our way, we shall dwell a little longer on this subject, which 
we deem not only interesting in itself, but essentially connected with cor- 
rect views in medical science 

When we consider the human body as divided into several subordinate- 
systems or parts, we know that a substance or agent which increases action 
in one of these parts, may, at the same time, diminish it in another — in other 
words, that the same substance which acts directly as a stimulus to the for- 
mer, may be indirectly a sedative to the latter. This sedative effect, how- 
ever, does not here arise from a sedative nature in the agent which produces 
it ; it results from what Dr Darwin calls, not improperly, the " reverse sym- 
pathies" of living matter. The substance is, as to its own qualities, a pure 
stimulus, because it augments the action of the part with which it comes in 
immediate contact; it becomes a sedative only in consequence of the struc- 
ture and associations of the body on which it acts. 

A blistering plaster applied to the thorax, in a case of peripneumony, or 
to the head, in a case of phrenitis, increases in each case the action of the 
external skin ; but diminishes, in the former, the action of the pleura, and, 
in the latter, that of the dura mater. No one, however, dreams of bestow- 
ing on cantharides the name of a sedative. 

If a few grains of tartarized antimony be swallowed, they stimulate the 
stomach into violent action ; but reduce very greatly the action of the arte- 
ries. Notwithstanding this remote sedative effect, no medical writer of the 
present day will venture to call this preparation of antimony any thing but 
a stimulus. Its sedative operation arises entirely from the sympathies of 
the body on which it acts. The same thing may be said in relation to oxyde 
of arsenic and corrosive sublimate. If swallowed in considerable quantities, 
they stimulate the stomach to inordinate action ; but diminish, at first, in an 
equal degree, the action of the arteries. By no one, however, are they re- 
garded in the light of sedatives. 

Opium, although acknowledged by all to be the most powerful stimulus, 
operates, notwithstanding, as a sedative to the nerves. It is by this secon- 
dary mode of action that it relieves pain. 

The strongest artificial caustics, and the actual cautery itself, are applied 
to the skin to reduce, and do reduce, the action of certain internal parts 
when in a state of inflammation. Even these substances, therefore, operate 
as sedatives through the medium of sympathy. 

Thus might we examine by analysis the whole materia medica, and show 
that every article which it contains, may, hy the mode in which it is em- 
ployed, be made to produce, on some part of the human body, a sedative 
effect ; and yet, that each article in itself is strictly a stimulus, because it 



102 PRACTICE OF PHYSIC. 

same time I hope to avoid several errors which have 
formerly prevailed on this subject. 

excites, in every instance, an increase of action on the part to which it 19 
proximately applied. 

That which produces excitement, say those who have the reputation of 
being most deeply versed in this doctrine, is a stimulus. But excitement, 
as applied to man, consists in motion, sensation, and thought. Whatever, 
therefore, produces, in man, the phenomena of motion, sensation, and 
thought, or either of them, is necessarily a stimulus. 

Had we leisure to examine cold, on the principles of the doctrine of sti- 
mulation contained in this syllogism, we should find it, in its action, to agree 
with them most perfectly in every respect. Heat, perhaps, alone excepted, 
there does not appear to exist in nature another agent, which surpasses 
cold in its manifestation of the characters and effects of a stimulus. It pro- 
duces sensation, as the term itself implies; for the sensation of cold is as 
familiar an expression as that of heat. It might even, perhaps, be stated as 
a question, which of the two sensations is capable of being raised to the 
most tormenting height ? intense cold being quite as painful as a severe 
burn. If heat be a stimulus to the nerves, therefore, so is cold : for the laws 
which govern them and the phenomena they exhibit are precisely alike. 
But sensation implies nervous motion. In producing the former, therefore, 
cold cannot possibly fail to produce the latter also. 

In man, motion and sensation, by a law of our nature, excite attention! 
which, being an intellectual operation, is tantamount to thought. Hence it 
is plain, that cold is capable of giving rise to the three only modes of ex- 
citement that stimuli produce — motion, sensation, and thought. Cold is, 
therefore, itself a stimulus. 

Like other agents, cold is not capable of producing excitement in every 
part of our systems at once. The laws of animal sympathy prevent this. 
While it operates as a stimulus on one part or subdivision of our bodies, its 
effect on another is that of a sedative. 

If water, at the temperature of forty degrees of Fahrenheit, be applied 
for a time to the wrists and ankles, it reduces very considerably the force 
and frequency of arterial action ; but produces, at the same time, a strong 
sensation. While it is a sedative to the arteries, therefore, it cannot be 
denied to be a stimulus to the nerves and skin It excites the part with 
which it comes in contact. It operates here, in a manner precisely analo- 
gous to ipecacuanha, digitalis, tartarized antimony, and many other sub- 
stances which we need not enumerate. Those articles, when swallowed in 
a sufficient quantity, stimulate the stomach, but, by sympathy, act as a seda- 
tive to the arteries. Cold stimulates the skin, but acts as a sedative to the 
same parts. 

We shall conclude our remarks on cold by observing, that were it practi- 
cable for us to pass, in analytical detail, through the whole doctrine respect- 
ing that agent, it would be easy to show, that every law, principle and phe- 
nomenon of stimulation are as applicable to it, as they are to heat or opium, 
cantharides or alkohol. Nor can there be produced a single fact, in rela- 



PRACTICE OF PHYSIC. JOS 

34. As the hot stage of fever is so constantly pre- 
ceded by a cold stage, we presume that the latter is the 

tion to the action of cold on living matter, which is not perfectly explicable 
on the ground of its being possessed of stimulating powers. 

Having declared our disbelief in the existence of any substance or agent 
strictly entitled to the denomination of a sedative, it follows, of course, that 
we differ from Dr. Cullen, in his opinion respecting the nature of febrile 
contagions. We consider these poisons as powerful stimulants. Indeed, 
the very idea of a sedative poison involves an inconsistency, which, in our 
estimation, nothing can surpass. All poisons act by stimulation ; and those 
which do not overwhelm life instantaneously, by a first impression, destroy 
it ultimately through the medium of inflammation. 

Of febrile contagions, it is much to be regretted, that, philosophically 
speaking, we know but little. Among the great variety that is supposed to 
exist, there are only two that we have been able to realize, take hold of, 
and bring completely to the test of experiment. These are, the contagion 
of small pox and the contagion of kine pox. Of those two poisons, the 
nature cannot possibly now be a topic of controversy. Their stimulating 
qualities are as susceptible of demonstration, and are, indeed, as often de- 
monstrated, as any truth in the science of physics. By the puncture of a 
lancet, introduce either of them beneath the cuticle, and, in a few hours, 
inflammation ensues It is needless to say that this would not be the case, 
were they of a sedative nature. 

Yet the poison of small pox, when casually introduced into the human 
system, produces, oftentimes, as much debility as marks the character of 
even typhus gravior, cynanche maligna, or any other febrile disease : and it 
seems to be in consequence of their debilitating effects, that Dr. Cullen 
and other writers have bestowed on contagions the name of sedatives. 

These poisons, say those writers, when acting on the body of man, dimi- 
nish its powers: but the diminishing of power is a sedative process; the 
substances in question are consequently sedatives. 

This syllogism, although plausible in appearance, is utterly fallacious. By 
a similar mode of reasoning, there is nothing capable of seriously injuring 
the human body, that may not be clearly proved to be a sedative. 

Thus, for example, arsenic and corrosive sublimate, vitriolated copper 
and opium, if taken in excessive quantities, produce extreme debility in 
the system. If a pint of alkohol be swallowed at a draught, it greatly debi- 
litates, and is, perhaps, even productive of sudden death. Does it, there- 
fore, follow that these articles are sedatives ? It certainly doe9 not : no phy- 
sician of the present day will venture to call them so : they are acknow- 
ledged to be stimulants of the highest order. 

A severe blow on the head, a deep and extensive burn on the surface of 
the body, and the passage of a bullet or a bayonet through the Jungs or the 
stomach, are all productive of great debility : yet no one will contend that 
wounds, burns, and blows are sedative agents. 

The production of debility by a stimulating agent is a phenomenon easily 
explained. 



104 PRACTICE OF PHYSIC. 

cause of the former; and therefore that the cause of the 
cold stage is the cause of all that follows in the course 
of the paroxysm. — See Boerh. Aph. 1756. 

The human body is a compound of sympathizing organs. Its power de- 
pends on the harmonious action of all its parts. The healthy condition of 
each important subdivision is necessary to the strength of the entire ma- 
chine. Of these organs or subdivisions the stomach must be regarded as one 
of the principal. Whatever materially injures the stomach, therefore, im- 
pairs the force of the whole system. 

Of stimuli, some are deleterious in their own nature, and others are ren- 
dered so by an excess in quantity. Of the former description are arsenic 
and corrosive sublimate ; and of the latter, wine and ardent spirits. 

W r hen by either of these articles the stomach is too powerfully acted on, 
its healthful harmony with the other parts of the body is, for the time, de- 
stroyed. It no longer extends to them its natural and invigorating sympa- 
thies, nor imparts to them the strength they have usually derived from it. 
However much, therefore, its own action may be increased by means of 
the stimulus within it, the action of the system at large is greatly dimi- 
nished. The general effect is that of debility ; not because a real sedative 
is in operation on the system, but because the functions and strengthening 
associations of the stomach are materially impaired by the action of stimu- 
lus. That organ, which is a governing one, and, in relation to its associates, 
resembles the sun in the solar system, no longer performs its destined part. 
The others, being deprived of the chief impu'se which awakened and put 
them in motion, and of the power of attraction which drew together their 
living energies, lose, in a great measure, their efficiency and force. The cen- 
tre of the confederacy being disordered, sickness and debility cannot fail to 
pervade the whole : the keystone of the arch being shattered and loosened, 
the entire structure is weakened, and in danger of falling to pieces. 

The same thing is true, to a certain extent, if, by means of a stimulus, a 
material injury be done to the brain, the lungs, the heart, the intestines, the 
kidneys, the liver, the testicles, or any other important organ of the body. 
A general sedative effect ensues : the strength of the system is necessarily 
impaired, in a degree corresponding to the weight of the suffering organ 
and the injury it has sustained. 

As we shall have occasion, hereafter, to express our sentiments some- 
what fully on the subject of febrile contagions, we shall, at present, only 
add, that we believe these poisons to be considered by physicians as much 
more numerous than they really are. 

With Dr. Cullen's theory of fever we have expressed ourselves dissatis- 
fied. Viewed as a whole, we consider it an unqualified tissue of error, 
equalled only by that which a late distinguished American teacher so indus- 
triously laboured to erect on its ruins. 

With the Edinburgh professor we confidently believe in the existence of a 
ww medicatrix naturct — an active power, whose office is to preserve nnd re- 
Store the health of the body. The operations of this power are conclu- 



PRACTICE OF PHYSIC. 105 

35. To discover the cause of the cold stage of fe- 
vers, we may observe, that it is always preceded by 

sively manifested in the healing of wounds, the knitting of fractured bones, 
the ejection of deleterious substances from the stomach, and many other 
processes which we cannot now enumerate. Were it not for its action and 
aid, recovery from disease would be absolutely impossible. Man's first ma- 
lady would necessarily be his last, by a law of nature which human exer- 
tions would be unable to countervail. 

No enlightened and honest physician will venture to say, that, by his re- 
medies alone, he ever gave health to a single individual. The utmost of his ser- 
vices has been, to -weaken disease, leaving to nature the final and complete 
restoration of health. 

When the malady is slight — a moderate fever, for example, or a common 
catarrhal affection — nature, unassisted, is perfectly competent to the cura- 
tive process. Hence, in such cases, medical aid is rarely solicited. In com- 
mon language, the disease is said to get well of itself. This, however, is 
not the case. Medical science disavows the fact. As no malady can occur 
without the agency of a morbific cause, neither can it be removed without 
the aid of a curative one. But where no medicines are administered, the 
only curative cause that can be supposed to be in operation is necessarily 
the vis medicatrix natural. 

In diseases so violent as to call for remedies, all that these remedies can 
effect is, so far to weaken morbid action, as to render it manageable by the 
powers of nature. A powerful malady is converted into a weak one, and 
nature then completes its removal. To the truth of these remarks there is 
no exception. A physician can no more, by his own exertions, cure a dis- 
ease, than a surgeon can an incised wound. The latter places the separated 
parts in contact, retains them there by a suitable apparatus, recommends to 
his patient the necessary regimen, and leaves to natilre the curative process. 
Nor is it in the power of the former to proceed further. If he be perfectly 
versed in his profession, he reduces the system of his patient to the proper 
state of action with regard to force, enjoins rest, prescribes the regimen 
which the case demands, and, for a final cure, trusts alone to the vis medi- 
catrix. Hence it requires in a practitioner as much skill and experience to 
know when to withhold his remedies, as when to administer them. 

Although, for the foregoing reasons, we believe in the existence of a heal- 
ing power in nature, we are by no means satisfied with the exposition of its 
operations, which Dr Cullen has attempted, in his theory of fever. His 
reasoning on the subject is forced and artificial, unsatisfactory and confused. 

For the principles of what we consider a correct theorv of fever, we can- 
not do better than refer our readers to Darwin's Zoonomia. We be! eve, 
with the very acute and distinguished author of that work, that fever is 
essentially a disease of association — that it is formed alone through the me- 
dium of sympathy. It begins, as we have said, in another place, at a point, 
and spreads throughout the system, instituting a chain of diseased associated 
motions, consisting of as many links as there are parts or subdivisions of the 
body affected. 

VOL. I. O 



106 PRACTICE OF PHYSIC. 

strong marks of a general debility prevailing in the sys- 
tem. The smallness and weakness of the pulse, the 

Dr. Clutterbuck is also an advocate fbr the doctrine of the original loca- 
lity of fever. But he places the primary irritation in the brain. In this he is 
mistaken, as it shall be, presently, our business to endeavour to prove. 

To illustrate a little further. We are persuaded that most febrile diseases 
have thiir origin or first topical affection in the stomach, the skin, or that 
portion of the Schneiderian membrane which lines the fauces, the trachea, 
and the bronchia. We feel satisfied that all malignant fevers, in particular, 
have their seat in the stomach. In the blood-vessels, the nerves, the lym- 
phatics, the brain, orthe glands, they cannot originate, for the strongest of 
reasons : to these parts the causes producing them cannot have primary 
access. 

Having commenced in its customary seat, the stomach, fever proceeds to 
invade, by sympathy, the nerves, the skin, the blood-vessels, the lymphatics, 
the glands, and the brain, until its chain of associated diseased action em- 
braces, at length, the entire system. Commencing in the skin, as some, 
perhaps, of the phlegmasia and hemorrhagic do, it, on the same principles, 
pursues a similar march, until it has formed a chain of equal extent. On no 
other ground of explanation than this, do we consider fever as an intelligible 
disease. 

Although we consider Dr. Darwin correct in his general principles and 
outline of fever, he has attempted to introduce into his exposition so much 
of the minutiae of associated action, as to render it, to us, in some parts, unin- 
telligible. Much interesting and important information, however, may be 
derived from his writings on this subject. 

We observe that, in the medical school of New York, there is on foot, 
under the auspices of our able and very distinguished friend, Dr. Hosack, an 
attempt to revive no inconsiderable portion of the long-exploded doctrines 
of the Humoral Pathology. A full and lucid exposition of what we believe 
to be the professor's views on this subject may be seen in Dr. Dyckman's 
learned and well written Inaugural Dissertation, for the year 1814 

Against this attempt we would be understood as bearing, most delibe- 
rate!}, our decided testimony. Sound pathology consists in the history and 
philosophy of the diseased action of our solids, not of the vitiated condi- 
tion of our fluids. Even admitting that the humours of the body do be- 
come somewhat changed from their natural and healthy condition, it is as a 
consequence, not an original cause of disease — the result, not the origin of 
morbid action. 

Although the New York school does not appear to be an advocate for 
the real putridity of the blood during life, but contents itself with maintain- 
ing its putrescency only ; it asserts its full and confident belief, not in the 
mere vitiation of that fluid by means of the severaJ morbific poisons, but in 
its actual assimilation to their nature and qualities. According to the tenets 
of that seat of science, the matter of small pox produces in the blood a va- 
riolous taint, the matter of kine pox a vaccine taint, and the matter of mea- 
sles a morbillous taint; each poison assimilating that fluid to its own charac- 



PRACTICE OF PHYSIC, 107 

paleness and coldness of the extreme parts, with the 
shrinking of the whole body, sufficiently show that the 

ter, and rendering it capable, by inoculation, of communicating the disease 
to which the poison appertains. 

This doctrine is signally erroneous. It is contrary alike to the issue of ex- 
perience, and the principles of legitimate and sound physiology. 

On the ground of experiments made by ourselves, we assert that the 
blood of persons affected by small pox, kine pox, and measles, will not com- 
municate those diseases. We even avow our disbelief in the communicabi- 
lity of measles by any mode of inoculation. We have endeavoured to com- 
municate it by every way we could devise, inserting under the cuticle of 
the person inoculated, the blood, the tears, the mucus secreted by the 
Schneiderian menfbrane, and even the matter of eruption of the individual 
diseased, but have always failed. 

If the proper precautions be observed in the drawing of blood, and in 
the performance of the act of inoculation, we repeat, that that fluid cannot 
be rendered instrumental in the propagation of any contagious disease- 

In a contagious fever — suppose it to be a case of casual small pox — through 
what channels can the poison gain admission to the blood ? We answer, 
through two only — the lacteals or cutaneous lymphatics. Nature has pro- 
vided no other ; nor can art form one. 

To physiologists, the nice appetency or power of selection of these organs 
is well known. They admit into their mouths, and convey to the thoracic 
duct, no admixture of heterogeneous materials. To nothing will they grant 
admission and conveyance, until it be digested and assimilated to an uniform 
mass. If they take up bone or muscle, fat or glandular matter, they receive 
neither of them in its formal character. Each must undergo a preparatory 
process, by which it is divested of its specific properties, and made to as- 
sume the character of chyle or lymph. 

Such must be also the case in relation to contagion. If it be taken up by 
the absorbents at all, it cannot enter them in its formal state. They do not 
receive it while armed in all its deleterious qualities. It must have laid 
these aside, and become one of the component parts of lymph or chyle. 
Thus changed, it is no longer contagion, and can produce no other than a 
common effect on the blood, tending to augment, not to vitiate it. 

But the truth is, that no febrile poison ever enters the absorbents in any 
form Its very nature as a poison prevents this. It attaches itself to some 
spot in the system, and produces there a peculiar irritation, which is propa- 
gated by sympathy from one part to another, until the whole experiences 
its deleterious influence. Its action is therefore confined to the solids alone, 
the fluids participating in none of its qualities. 

Whether we attempt an investigation of the modus operandi of conta- 
gions, in the production of fevers, or of remedies, in their cure, we must 
confine our attention to the solids of the body. Be it of a nature deleteri- 
ous or sanative, it is through them alone that the work is effected. Our 
present views of physiology lead to a disbelief in the medication, no less 
than in the contamination, of the human fluids. Whatever enters the lac 



108 PRACTICE OF PHYSIC. 

action of the heart and larger arteries is, tor the time, 
extremely weakened. Together with this, the languor, 

teals enters them as chyle, and, as such, is intended for nutriment ; not to 
communicate to the blood either medicinal or morbific qualities. 

The facts, that madder passes through the blood, and tinges the bones of 
animals red ; that, some time after the articles have been themselves swal- 
lowed, the odour of asparagus, spirits of turpentine, and garlic is discover- 
able in the urine and matter of perspiration ; that the taste of certain vege- 
tables which have been eaten becomes perceptible in the milk of females ; 
and that in the blood of a person long accustomed to the use of soda, as a- 
medicine, a great superabundance of that substance has been found — these 
facts, we say, with various others somewhat similar, that might be easily 
cited, furnish no argument of weight against our opinion. 

That the articles just mentioned have made their way into the blood, will 
not be denied. But they entered it, not in a crude and formal state, but as 
a digested and assimilated portion of chyle. Hence they became a com- 
ponent part of the blood itself, perfectly homogeneous with its other parts. 
But when that fluid had lost its vitality, and become decomposed in the 
crucible of the chemist, the soda, which it contained in substance, not in 
form, was immediately revived. It is thus that both soda and potash are 
formed, by combustion, from plants, which contain nothing but the raw ma- 
terials out of which these articles are made. Without combustion they 
. cannot be obtained, although substantially present in the plant. 

It is for a similar reason that the smell and taste of certain alimentary 
and medicinal matters are perceptible in the secretions and excretions of 
of the body. These qualities are not found in the blood, that fluid retaining 
its usual taste and odour. They are only revived in the fluids secreted 
from it, by means of the chemical affinities, which, being now permitted to 
act, uncontrolled by the powers of assimilation, recompose the peculiar 
forms of matter, wherein the taste and smell of the plants existed. In the 
urine of a person that has eaten asparagus, the smell of that plant is revived 
by chemical affinity; although it is not present in the blood whence the 
urine is prepared ; and, in the milk of a cow that has eaten garlic, both the 
taste and smell of that vegetable are chemically revived, while the blood 
of the animal is entirely exempt from them. 

A very strong ground of belief that no crude unassimilated materials are 
ever, during life, admitted into the mass of blood, is, that if such articles 
be introduced into the blood-vessels, even in the greatest state of dilution, 
immediate and great suffering, if not actual death, is the inevitable conse- 
quence. 

In treating of the causes of fevers, we feel persuaded that Dr. Cullen has 
fallen into a common error, attributing to contagion much more than justly 
belongs to it. Strictly speaking, the number of contagious febrile diseases 
is very limited. In our estimation, the order Febres of our author does 
not contain one. We believe they are all included under that of Exanthe- 
mata. Belonging to this order, the number of diseases unequivocally con- 



PRACTICE OF PHYSIC. 109 

inactivity, and debility of the animal motions, the im- 
perfect sensations, the feeling of cold, while the body 

tagious does not exceed four, — small pox, kine pox, chicken pox, and mea- 
sles. Even of the two latter complaints, the contagion is by some physi- 
cians considered as doubtful. 

All febrile poisons are not contagions. Those resulting from putrefac- 
tion, whether of animal or vegetable substances, ought not to be so deno- 
minated. We have already mentioned, and beg leave to repeat, that-conta- 
gion is a secreted poison — the result of morbid animal action. By way of 
distinction, febrile poisons arising from putrefaction have been denominated 
infections. By the late Dr. Miller of New York, terms were applied to 
these two species of morbific causes, which ought not to be rejected without 
due consideration. If we are not mistaken, they serve the purpose of accu- 
rate discrimination better than any others that have been heretofore in- 
vented. 

To febrile poisons resulting from putrefaction, that writer gave the name 
Koino — from the Greek word kwos, which signifies common— pointing out the 
extent and community of their origin ; thus making the compound term, 
Koino-miasmata, common febrile poisons. On those arising from diseased 
secretory action he bestowed the epithet Idio — from the Greek word af/oc, 
peculiar or specific — expressing thereby, at once, the peculiarity of their 
origin, and their specific character ; and designating them by the compound 
term Idio miasmata, specific febrile poisons. 

Contagion being the offspring of morbid glandular action, to render its 
existence certain, the glands which secrete it must have themselves an ex- 
istence. But of their existence we cannot be certain, unless they be visi- 
ble .- and how very few are the febrile diseases that are unequivocally 
marked by morbid glands ! Small pox, kine pox, and chicken pox, consti- 
tute, perhaps, the whole amount. In measles and the other exanthemata, 
the existence of such bodies is far from being certain. Nor is the case dif- 
ferent with regard to typhus, synochus and dysentery. In these diseases no 
morbid glands, nor any thing tantamount to them, ever appear. Hence one 
cause of denying them a contagious character. 

There does not, perhaps, exist in medical science a point of doctrine that 
stands on so unstable a foundation, and is, at the same time, so loosely 
constructed, as that which treats of febrile contagion. On other points we 
require, for our satisfaction, experimental demonstration s here we rest con- 
tented with the most equivocal appearances — such as scarcely lay a founda- 
tion for the feeblest probability. 

A. disease, marked by a few unusual symptoms, attacks at once, or in suc- 
cession, a family, a neighbourhood, or an entire community. This is suffi- 
cient ; nothing further respecting it is sought for. .No inquiry is instituted 
as to its real nature. The mere circumstance of numbers suffering from it is 
deemed sufficient to fix its character. It is without hesitation pronounced 
to be contagious. Yet there does not exist on the persons of those who are 
subject to it., a single glandular body or character by which a morbid poison 
could be secreted. No change of moment has taken place in them except 



110 PRACTICE OF PHYSIC. 

is truly warm, and some other symptoms, all show that 
the energy of the brain is, on this occasion, greatly 

what is common to febrile diseases. Neither in their secretions nor excre- 
tions does any thing unusual or suspicious appear. 

In a case like this, there is no solid ground for a belief in contagion. A 
disease spreads and becomes general in a neighbourhood from sundry other 
causes — bad water, damaged provisions ; but more especially from a vitiated 
atmosphere. It is well known that, in consequence of atmospheric influ- 
ence, even peripneumony, rheumatism, angina inflammatoria, croup, and 
other diseases never suspected of contagion, assume, at times, an epidemic 
prevalence — they run through families and neighbourhoods, towns, and 
cities. 

We have in another place observed, that contagion, strictly so called, is a 
specific substance, else it would not be contagion — it would not, as it does, 
possess powers of self propagation. These powers, which bestow on it its 
character, it exercises absolutely, on all occasions, and in a specific and uni- 
form manner, independently of season, situation, temperature, and all other 
adventitious circumstances. It is a positive virus, and poisons certainly, 
from its own qualities, whenever it is applied to a susceptible subject. This 
it does as well in the rigours of January, as in the heats of August ; in an 
open, no less than in a confined situation ; and in the pure and salubrious 
air of the country, as readily as in the vitiated atmosphere of a large city. 
Such is the case with the contagions of small pox, kine pox, and lifes vene- 
rea. Seasons, situations, and qualities of the atmosphere are totally indif- 
ferent to these poisons. They act from their own inherent powers, with as 
much certainty as opium or arsenic, corrosive sublimate, or any other dele- 
terious article. 

When we find a disease, therefore, that is either of a local or a temporary 
character— one that prevails and spreads during the summer and autumn, 
and in the crowded streets and alleys of a large city, but disappears on the 
occurrence of cold weather, and can never be propagated in open and freely 
ventilated situations in the country — or another which prevails during cold 
weather, and in towns, hamlets, and country situations, but ceases on the 
approach of summer, and is scarcely known in large cities. — When we find 
febrile diseases of this description, we should be cautious in attributing to 
them the qualities of contagion. We may feel confident, indeed, that their 
prevalence arises, not from that, but from other causes Hence, both typhus 
fever, yellow fever, and even pestis vera, want characteristics sufficient to 
prove them to he contagious diseases. These complaints are known to be 
circumscribed in their prevalence, both as to place and time. Pestilence 
and yellow fever spread only during warm weather, and in a vitiated atmo- 
sphere ; typhus fever requires also a vitiated atmosphere, but prevails most 
during cool weather. The miasmata of the former become sufficiently abun- 
dant to contaminate the air of a whole city; those of the latter can seldom 
do more than vitiate that of a single.building; or perhaps only of a single 
apartment. Perfect atmospheric purity is as fatal to them all, as an entire 
want of food is to animal life— and for the same reason -, it deprives them of 



PRACTICE QF PHYSIC. HI 

weakened; and I presume, that as the weakness of the 
action of the heart can hardly be imputed to any other 

the aliment necessary to their existence. These complaints have no power 
to form, by disordered vascular action, a contagion sufficient for their own 
propagation : unless, therefore, the poison be otherwise produced, it fails, 
and their course is necessarily arrested. 

The accounts we have in print relative to inoculation for the plague, are 
entitled to no regard. The matter used for the purpose was taken from 
bubos or carbuncles. But these are not essential murks of the disease. In 
a very great majority of the cases of plague there are neither carbuncles 
nor suppurated bubos. 

In these there can, of course, be no contagion. There must be, therefore, 
two species of the same complaint; one communicable and the other not. 
Such a supposition, however, is not admissible : it is even absurd. Plague 
is either contagious, in its nature, and, therefore, in every instance ; or it is 
not contagious at all. 

Again : we have no knowledge of the proper method of inoculating for 
plague. All poisons do not take effect on every part of the body. Arsenic 
and corrosive sublimate, introduced into a small wound in the skin, produce 
but little inconvenience. Brought into contact with the stomach, they are 
active and dangerous The reverse is true with regard to the poison of the 
viper and the rattlesnake. Introduced into a wound, it is highly deleteri- 
ous; whereas it may be swallowed with perfect impunity. 

Something similar may be true with regard to pestis vera, even admitting 
the disease to be contagious. A puncture in the skin may not be the pro- 
per place for the insertion of the poison. The virus may be inefficient 
there, although active elsewhere. To render it effective, it may be requi- 
site, perhaps, to bring it into contact with the stomach, or some part of the 
Schneiderian membrane. Possibly a similar mistake, as to the proper place 
of insertion, may be the reason why all attempts to inoculate for measles 
have failed. 

Further : in the very few cases wherein inoculation is said to have pro- 
duced the plague, we know nothing of the progress or particulars of the 
operation. We are simply told, that persons who had been inoculated were 
attacked by the disease ; but are left at an entire loss as to the source 
whence it was derived — inoculation or casual infection Did the envenomed 
puncture inflame and pass through such a marked and regular series of 
stages, as to appear manifestly to be the cause of the disease ? or did the com- 
plaint succeed the inoculation without the occurrence of any such pheno- 
mena ? Did the period of time that elapsed, from the operation to the attack, 
justify the belief that they stood related to each other as cause and effect ? 
These are points respecting which we are totally uninformed Yet a know- 
ledge of them is essential to our understanding of the cases to which they 
relate. 

For the reasons herein given we feel persuaded that the number of truly 
contagious diseases is much more limited than it is generally supposed to 
be. 



112 PRACTICE OF PHYSIC. 

cause, this weakness also is a proof of the diminished 
energy of the brain. 

36. I shall hereafter endeavour to show, that the 
most noted of the remote causes of fever, as contagion, 
miasmata, cold and fear, are of a sedative nature; and 
therefore render it probable that a debility is induced. 
Likewise, when the paroxysms of a fever have ceased 
to be repeated, they may again be renewed, and are 
most commonly renewed by the application of debilitat- 
ing powers. And further, the debility which subsists 
in the animal motions and other functions through the 
whole of fever, renders it pretty certain that sedative 
or debilitating powers have been applied to the body. 

37. It is therefore evident, that there are three states 
which always take place in fever: a state of debility, a 
state of cold, and a state of heat; and as these three 
states regularly and constantly succeed each other in 
the order we have mentioned them, it is presumed that 
they are in the series of cause and effect with respect 
to one another. This we hold as matter of fact, even 
although we should not be able to explain in what man- 
ner, or by what mechanical means these states several- 
ly produce each other. 

38. How the state of debility produces some of the 
symptoms of the cold stage, may perhaps be readily 
explained; but how it produces all of them, I cannot 
explain otherwise than by referring the matter to a 
general law of the animal economy, whereby it happens, 
that powers which have a tendency to hurt and destroy 
the system, often excite such emotions as are suited to 
obviate the effects of the noxious power. This is the 
vis medic atrix nature, so famous in the schools of 
physic; and it seems probable, that many of the motions 
excited in fever are the effects of this power. 

39. That the increased action of the heart and arte- 



PRACTICE OF PHYSIC. 113 

ries, which takes place in the hot stage of fevers, is to 
be considered as an effort of the vis medicatrix natures, 
has been long a common opinion among physicians; 
and I am disposed to assert, that some part of the cold 
stage may be imputed to the same power. I judge so, 
because the cold stage appears to be universally a means 
of producing the hot; because cold, externally applied, 
has very often similar effects; and more certainly still, 
because it seems to be in proportion to the degree of 
tremor in the cold stage, that the hot stage proceeds 
more or less quickly to a termination of the paroxysm, 
and to a more complete solution and longer intermis- 
sion. See SO. 

40. It is to be particularly observed, that during the 
cold ^tage of fever, there seems to be a spasm induced 
every where on the extremities of the arteries, and more 
especially of those upon the surface of the body. This 
appears from the suppression of all excretions, and from 
the shrinking of the external parts: and although this 
may perhaps be imputed in part to the weaker action of 
the heart in propelling the blood- into the extreme ves- 
sels; yet, as these symptoms often continue after the 
action of the heart is restored, there is reason to believe 
that a spasmodic constriction has taken place; that it 
subsists for some time, and supports the hot stage; for 
this stage ceases with the flowing of the sweat, and the 
return of other excretions, which are marks of the re- 
laxation of vessels formerly constricted. Hoffman. Med. 
rat. System. Tom. 4. P. 1. Sect. 1. Cap. 1. art. 4. 

41. The idea of fever, then, may be that a spasm of 
the extreme vessels, however induced, proves an irrita- 
tion to the heart and arteries, and that this continues till 
the spasm is relaxed or overcome. There are many 
appearances which support this opinion; and there is 
little doubt that a spasm does take place, which proves 

vol. i. p 



114 PRACTICE OF PHYSIC 

an irritation to the heart, and therefore may be con- 
sidered as a principal part in the proximate cause of 
fever. It will still, however, remain a question, what 
is the cause of this spasm; whether it be directly pro- 
duced by the remote cause of fever, or if it be only a 
part of the operation of the vis medicatrix natnrce. 

42. I am disposed to be of the latter opinion, because 
in the first place, while it remains still certain that a 
debility lays the foundation of fever, it is not obvious in 
what manner the debility produces the spasm, and what 
seems to be its effect, the increased action of the heart 
and arteries; and secondly, because, in almost all the 
cases, in which an effort is made by the vis medicatrix 
naturae, a cold fit and a spasm of the extreme vessels 
are almost always the beginnings of such an effort. See 
Gaub. Pathol. Medicin. art. 750. 

43. It is therefore presumed, that such a cold fit and 
spasm, at the beginning of fever, is a part of the opera- 
tion of the vis medicatrix; but, at the same time, it 
seems to me probable, that during the whole course of 
the fever, there is an atony subsisting in the extreme 
vessels, and that the relaxation of the spasm requires 
the restoring of the tone and action of these. 

44. This it may be difficult to explain; but I think it 
may be ascertained as a fact, by the consideration of the 
symptoms which take place, with respect to the func- 
tions of the stomach in fevers, such as the anorexia 
nausea, and vomiting. (14.) 

From many circumstances it is sufficiently certain, 
that there is a consent between the stomach and the 
surface of the body: and in all cases of the consent of 
distant parts, it is presumed to be by the connection of 
the ervous system, and that the consent which appears 
between the sentient and moving fibres of the one 
part with those of the other, is such, that a certain con- 



PRACTICE OF PHYSIC. 115 

dition prevailing in the one part, occasions a similar 
condition in the other. 

In the case of the stomach and surface of the body, 
the consent particularly appears by the connection which 
is observed between the state of the perspiration, and 
the state of the appetite in healthy persons; and if it may 
be presumed that the appetite depends upon the state 
of tone in the muscular fibres of the stomach, it will 
follow, that the connection of appetite and perspiration 
depends upon a consent between the muscular fibres of 
the stomach, and the muscular fibres of the extreme 
vessels, or of the organ of perspiration, on the surface 
of the body. 

It is further in proof of the connection between the 
appetite and perspiration, and at the same time of the 
circumstances on which it depends, that cold applied to 
the surface of the body, when it does not stop perspira- 
tion, but proves a stimulus to it, is always a powerful 
means of exciting appetite. 

Having thus established the connection or consent 
mentioned, we argue, that as the symptoms of anorexia, 
nausea, and vomiting, in many cases, manifestly depend 
upon a state of debility or loss of tone in the muscular 
fibres of the stomach; so it may be presumed, that these 
symptoms in the beginning of fever, depend upon an 
atony communicated to the muscular fibres of the 
stomach, from the muscular fibres of the extreme vessels 
on the surface of the body. 

That the debility of the stomach which produces 
vomiting in the beginning of fevers, actually depends 
upon an atony of the extreme vessels on the surface of 
the body, appears particularly from a fact observed by 
Dr. Sydenham. In the attack of the plague, a vomit- 
ing happens, which prevents any medicine from remain- 
ing on the stomach; and Dr. Sydenham tells us, that 



110 PRACTICE OF PHYSIC, 

in such cases he could not overcome this vomiting but 
by external means applied to produce a sweat; that is, 
to excite the action of the vessels on the surface of the 
body. 

The same connection between the state of the stomach 
and that of the extreme vessels on the surface of the 
body, appears from this also, that the vomiting, which 
so frequently happens in the cold stage of fevers, com- 
monly ceases upon the coming on of the hot, and very 
certainly upon any sweat's coming out, (14.) It is, indeed, 
probable, that the vomiting in the cold stage of fevers, 
is one of the means employed by nature for restoring 
the determination to the surface of the body; and it is a 
circumstance affording proof, both of this, and of the 
general connection between the stomach and surface of 
the body, that emetics thrown into the stomach, and 
operating there, in the time of the cold stage, commonly 
put an end to it, and bring on the hot stage. 

It also affords a proof of the same connection, that 
cold water, taken into the stomach, produces an in- 
crease of heat on the surface of the body, and is very 
often a convenient and effectual means of producing 
sweat. 

From the whole we have now said on this subject, I 
think it is sufficiently probable, that the symptoms of 
anorexia, nausea, and vomiting, depend upon, and are 
a proof of, an atony subsisting in the extreme vessels on 
the surface of the body; and that this atony therefore, 
now ascertained as a matter of fact, may be considered 
as a principal circumstance in the proximate cause of 
fever. 

45. This atony we suppose to depend upon a diminu- 
tion of the energy of the brain; and that this diminution 
takes place in fevers, we conclude, not only from the 
debility prevailing in so many functions of the body, 



PRACTICE OF PHYSIC. H? 

mentioned above, (35.) but particularly from symptoms 
which are peculiar to the brain itself. Delirium is a fre- 
quent symptom of fever; and as from the physiology 
and pathology we learn that this symptom commonly 
depends upon some inequality in the excitement of the 
brain or intellectual organ; we hence conclude, that, in 
fever, it denotes some diminution in the energy of the 
brain. Delirium, indeed, seems often to depend upon 
an increased impetus of the blood, in the vessels of the 
brain, and therefore attends phrenitis. It frequently ap- 
pears also in the hot stage of fevers, accompanied with 
a headach and throbbing of the temples. But as the im- 
petus of the blood in the vessels of the head is often con- 
siderably increased by exercise, external heat, passions, 
and other causes, without occasioning any delirium; so, 
supposing that the same impetus, in the case of fever, 
produces delirium, the reason must be, that at the same 
time, there is some cause which diminishes the energy 
of Ae brain, and prevents a free communication between 
the parts concerned in the intellectual functions. Upon 
the same principles also, I suppose there is another 
species of delirium, depending more entirely on the 
diminished energy of the brain, and which may there- 
fore arise, when there is no unusual increase of the 
impetus of the blood in the vessels of the brain. Such 
seems to be the delirium occurring at the beginning of 
the cold stage of fevers, or in the hot stage of such 
fevers as show strong marks of debility in the whole 
system. 

46. Upon the whole, our doctrine of fever is expli- 
citly this. The remote causes (36.) are certain sedative 
powers applied to the nervous system, which diminish- 
ing tiie energy of the brain, thereby produce a debility 
in the whole of the functions, (35.) and particularly in 
the action of the extreme vessels, (43. 44.) Such, how- 



118 PRACTICE OF PHYSIC. 

ever, is, at the same time, the nature of the animal 
economy, (38.) that this debility proves an indirect 
stimulus to the sanguiferous system, whence, by the 
intervention of the cold stage, and spasm connected 
with it, (39. 40.) the action of the heart and larger 
arteries is increased, (40.) and continues so (41.) till it 
has had the effect of restoring the energy of the brain, 
of extending this energy to the extreme vessels, of re- 
storing therefore their action, and thereby especially 
overcoming the spasm affecting them ; upon the remov- 
ing of which, the excretion of sweat, and other marks 
of the relaxation of excretories, take place. 

47. This doctrine will, as I suppose, serve to explain 
not only the nature of fever in general, but also the va- 
rious cases of it which occur. Before proceeding, how- 
ever, to this, it may be proper to point out the opinions, 
and as I apprehend, the mistakes, which have formerly 
prevailed on this subject. 

48. It has been supposed, that a lentor or viscidity 
prevailing in the mass of blood, and stagnating in the 
extreme vessels, is the cause of the cold stage of fevers 
and its consequences. But there is no evidence of any 
such viscidity previously subsisting in the fluids; and as 
it is very improbable that such a state of them can be 
very quickly produced, so the suddenness with which 
paroxysms come on, renders it more likely that the 
phenomena depend upon some cause acting upon the 
nervous system, or the primary moving powers of the 
animal economy. See Van Swieten apud Boerh. Aph. 
775. 

49. Another opinion, which has been almost univer- 
sally received, is, that a noxious matter introduced into, 
or generated in, the body, is the proximate cause of 
fever; and that the increased action of the heart and 
arteries, which forms so great a part of the disease, is 



PRACTICE OF PHYSIC. H9 

an effort of the vis medicatrix naturce to expel this 
morbific matter; and particularly to change or concoct 
it, so as to render it either altogether innocent, or at 
least, fit for being more easily thrown out of the body. 
This doctrine, however, although of as great antiquity 
as any of the records of physic now remaining, and 
although it has been received by almost every school of 
medicine, yet appears to me to rest upon a very uncer- 
tain foundation. There are fevers produced by cold, 
fear, and other causes, accompanied with all the essen- 
tial circumstances of fever, and terminating by sweat; 
but, at the same time, without any evidence or suspi- 
cion of morbific matter. 

There have been fevers suddenly cured by a hagmor- 
rhagy, so moderate as could not carry out any consider- 
able portion of a matter diffused over the whole mass of 
blood; nor can we conceive how the morbific matter 
could be collected or determined to pass off by such an 
outlet as. in that case is opened. 

Even supposing a morbific matter were present, there 
is no explanation given, in what manner the concoction 
of it is performed ; nor is it shown that any such change 
does in fact take place. In certain cases, it is indeed 
evident, that a noxious matter is introduced into the 
body, and proves the cause of fever; but, even in these 
cases, it appears that the noxious matter is thrown out 
again, without having suffered any change; that the 
fever often terminates before the matter is expelled; 
and that, upon many occasions, without waiting the 
supposed time of concoction, the fever can be cured, 
and that by remedies which do not seem to operate 
upon the fluids, or to produce any evacuation. 

50. While we thus reason against the notion of fever 
being an effort of nature, for concocting and expelling a 
morbific matter; I by no means intend to deny that the 



120 PRACTICE OF PHYSIC. 

cause of fever frequently operates upon the fluids, and 
particularly produces a putrescent state of them. I ac- 
knowledge that this is frequently the case; but, at the 
same time, I maintain, that such a change of the fluids 
is not commonly the cause of fever; that very often it is 
an effect only; and that there is no reason to believe the 
termination of the fever to depend upon the expulsion 
of the putrid matter. 

51. Another opinion which has prevailed, remains still 
to be mentioned. In intermittent fevers, a great quan- 
tity of bile is commonly thrown out by vomiting; and 
this is so frequently the case, that many have supposed 
an unusual quantity of bile, and perhaps a peculiar 
quality of it, to be the cause of intermittent fevers. 
This, however, does not appear to be well founded. 
Vomiting, by whatever means excited, if too often re- 
peated, with violent straining, seems to be powerful in 
emulging the biliary ducts, and commonly throws out a 
great deal of bile. This will happen especially in the 
case of intermittent fevers. For, as in the state of 
debility and cold stage of these fevers, the blood is not 
propelled in the usual quantity into the extreme vessels, 
and particularly into those on the surface of the body, 
but is accumulated in the vessels of the internal parts, 
and particularly in the vena portarum; so this may 
occasion a more copious secretion of bile. 

These considerations will, in some measure, account 
for the appearance of an unusual quantity of bile in in- 
termittent fevers; but the circumstance which chiefly 
occasions the appearance of bile in these cases, is the 
influence of warm climates and seasons. These seldom 
fail to produce a state of the human body, in which the 
bile is disposed to pass off, by its secretories, in greater 
quantity than usual; and perhaps also changed in its 
quality, as appears from the disease of cholera, which 



PRACTICE OF PHYSIC. 121 

so frequently occurs in warm seasons. At the same time, 
this disease occurs often without fever; and we shall 
hereafter render it sufficiently probable, that inter- 
mittent fevers, for the most part, arise from another 
cause, that is, from marsh effluvia; while, on the other 
hand, there is no evidence of their arising from the state 
of the bile alone. The marsh effluvia, however, com- 
monly operate most powerfully in the same season that 
produces the change and redundance of the bile ; and 
therefore considering the vomiting, and other circum- 
stances of the intermittent fevers which here concur, 
it is not surprising that autumnal intermittents are so 
often attended with effusions of bile. 

This view of the subject does not lead us to consider 
the state of the bile as the cause of intermittents, but 
merely as a circumstance accidentally concurring with 
them, from the state of the season in which they arise. 
What attention this requires in the conduct of the dis- 
ease, I shall consider hereafter. 

52. From this view of the principal hypotheses which 
have hitherto been maintained with respect to the proxi- 
mate cause of fever, it will appear, that fevers do not 
arise from changes in the state of the fluids; but that, 
on the contrary, almost the whole of the phenomena of 
fevers lead us to believe, that they chiefly depend upon 
changes in the state of the moving powers of the animal 
system. Though we should not be able to explain all 
the circumstances of the disease, it is at least of some 
advantage to be led into the proper train of investiga- 
tion. I have attempted to pursue it; and shall now 
endeavour to apply the doctrine already delivered, 
towards explaining the diversity of fevers.* 

* Since finishing our remarks on the subject of sedatives, our attention 
has been attracted by the two following paragraphs in the works of Dr. 
Ferriar, where he is treating of remedies for the cure of Dropsy. 
VOL. I. Q 



122 PRACTICE OF PHYSIC 



CHAPTER III. 
OF THE DIFFERENCE OF FEVERS, AND ITS CAUSES 

53. TO ascertain the difference of fevers, I think it 
necessary to observe, in the first place, that every fever 
of more than one day's duration, consists of repeated, 
and in some measure separate paroxysms; and that the 

" The effect of fox-glove, in retarding the velocity of the pulse, as a direct 
sedative, was too striking to be long overlooked ; and when its application, 
to diminish morbid irritation in the vascular system, was once pointed out, 
the consequences of the idea were easily comprehended." 

"The fact," says he, in a note, referring to the word 'sedative? " is so 
decisive, that I do not hesitate to employ this term, notwithstanding the 
jargon with which the public has of late years been abused on the subject of 
sedatives." 

We do not affect to know what precise meaning it was the intention of 
our author to affix to the terms "jargon" and "abused „•" but if he meant to 
designate by them the practice of imposing on the public by an employ- 
ment of words either destitute of a meaning, or fraught with error, then are 
they strictly applicable to himself, and those other writers who contend for 
the existence of sedatives ; not to the advocates of the opposite doctrine. 

Dr. P'erriar pronounces Digitalis to be a direct sedative .• we, on the other 
hand, maintain that it is a direct and very powerful stimulant; and, in addition 
to what we have already advanced, submit, in support of our opinion, the 
following remarks. 

Of the immediate action of an article on apart not visible, we can best judge, 
by its immediate action on parts that are .- for it is not credible that an agent, 
of any description, can radically change its own nature — be a direct sedative 
in one instance, and a direct stimulant in another. Let us apply this rule — 
to the correctness of which we are not sensible that any exception exists — 
to determine the nature and action of Digitalis. 

If an incision be made in the hand, or a portion of the skin be abraded 
from any part of it, and a strong decoction of digitalis applied to the wound, 
or denuded surface, the immediate effect is irritation, smarting, and pain; 
which will be ultimately succeeded by active inflammation. 

If a similar decoction be dropped into the eye, severe smarting, pain, and 
an increased secretion of tears will be the consequence; and, in case the 
operation be several times repeated, inflammation will ensue. 

A strong decoction of digitalis thrown into the urethra will excite irrita- 
tion, and produce a puriform discharge, similar to that of actual gonorrhoea. 

The same decoction, placed on the tongue, is exceedingly bitter ant 1 
acrid to the taste. It certainly, therefore, stimulates the nerves of the part- 



PRACTICE OF PHYSIC. j^S 

difference of fevers taken notice of above (from 25. to 
30.) appears to consist in the different state of parox- 
ysms, and in the different circumstances of their repe- 
tition. 

54. That fevers generally consist of distinct, and in 
some measure separately repeated paroxysms, I have 
alleged above to be matter of fact; but I shall here en- 
deavour to confirm it, by assigning the cause. 

55. In every fever, in which we can distinctly ob- 
serve any number of separate paroxysms, we con- 
stantly find that each paroxysm is finished in less than 

for sensation, of whatever description it may be, is nothing but the result of 
nervous stimulation. 

If, in these several instances, the volatile spirit of ammonia be used in- 
stead of a decoction of digitalis, the result will be the same — the excite- 
ment of irritation, pain, and inflammation ; and every one will acknowledge 
that such excitement is produced by the stimulating- qualities of the spirit. 

Is it true, then, that digitalis can produce, as a sedative, the same effects 
which arise from the action of spirit of ammonia as a stimulant? or, that the 
former article can act as a direct stimulant to the«ye, the tongue, the urethra, 
or a denuded portion of muscle, and yet prove a " direct sedative" to the 
stomach and blood-vessels ? Of these questions, we cannot be persuaded, 
that any one will venture to maintain the affirmative. 

If, in the cases herein cited, spirit of ammonia produce excitement and 
inflammation, as a stimulant, digitalis must produce them as a stimulant also: 
and if this vegetable production be a stimulus to the eye and the tongue, to 
mucous surfaces and denuded flesh, and to every part, indeed, where its ac- 
tion can be examined, it follows, as an inference, which nothing, we think, 
but the folly or madness of hypothesis will controvert, that, when swallow- 
ed, it proves to the stomach a direct stimulus, and reduces the action of the 
vascular system through the medium of sympathy. 

It is reported, moreover, that in cases of death, after the administration 
of large and repeated doses of digitalis, unequivocal marks of inflammation 
have been discovered in the stomach. This fact we state on the ground of 
report alone, having never ourselves performed a dissection, with a view to 
the ascertainment of truth on the subject. 

To the several experiments already mentioned, a9 calculated to determine 
the nature of the action of digitalis, we might add, that if the powder of the 
dried leaves of this plant be taken into the nostrils, it will, like the powder 
of tobacco, produce irritation, and, sometimes, sneezing. 

Either these facts must be reconciled to the sedative nature of digitalis — 
an issue which we think impossible — or the hypothesis be abandoned as 
false and untenable. 



124, PRACTICE OF PHYSIC. 

twenty-four hours; but as I cannot perceive any tiling 
in the cause of fevers determining to this, I must pre- 
sume it to depend on some general law of the animal 
economy. Such a law seems to be that which subjects 
the economy, in many respects, to a diurnal revolution. 
Whether this depends upon the original conformation 
of the body, or upon certain powers constantly applied 
to it, and inducing a habit, I cannot positively deter- 
mine; but the returns of sleep and watching, of appe- 
tites and excretions, and the changes which regularly 
occur in the state of the pulse, show sufficiently, that 
in the human body a diurnal revolution takes place. 

56. It is this diurnal revolution which, I suppose, de- 
termines the duration of the paroxysms of fevers; and 
the constant and universal limitation of these paroxysms, 
(as observed in 55.) while no other cause of it can be 
assigned, renders it sufficiently probable, that their dura- 
tion depends upon, and is determined by, the revolution 
mentioned. And that these paroxysms are connected 
with that diurnal revolution, appears further from this, 
that though the intervals of paroxysms are different in 
different cases, yet the times of the accession of pa- 
roxysms are generally fixed to one time of the day; so 
that quotidians come on in the morning, tertians at 
noon, and quartans in the afternoon. 

51. It remains to be remarked, that as quartans and 
tertians are apt to become quotidians, these to pass into 
the state of remittents, and these last to become con- 
tinued; and that, even in the continued form, daily 
exacerbations and remissions are generally to be ob- 
served; so all this shows so much the power of diurnal 
revolution, that when, in certain cases, the daily exacer- 
bations and remissions are with difficulty distinguished, 
we may still presume, that the general tendency of the 
economy prevails, that the disease still consists of re- 



PRACTICE OF PHYSIC. \25 

peated paroxysms, and, upon the whole, that there is 
no such disease as that which the schools have called 
a continent fever. I expect that this doctrine will be 
confirmed by what I shall say hereafter, concerning 
the periodical movements observed in continued fevers. 

58. It being thus proved, that every fever of more 
than one day's duration, consists of repeated paroxysms; 
we, in the next place, remark, that the repetition of pa- 
roxysms depends upon the circumstances of the pa- 
roxysms which have already taken place. From what 
was observed (in 30. and 31.) it appears, that the longer 
paroxysms are protracted, they are the sooner repeated; 
and therefore, that the cause of the frequent repetition 
is to be sought for in the cause of the protraction 
of paroxysms. 

59. Agreeably to what is laid down in 46. and to the 
opinion of most physicians, I suppose, that in every fe- 
ver there is a power applied to the body, which has a 
tendency to hurt and destroy it, and produces in it cer- 
tain motions which deviate from the natural state; and 
at the same time, in every fever which has its full 
course, I suppose, that in consequence of the constitu- 
tion of the animal economy, there are certain motions 
excited, which have a tendency to obviate the effects 
of the noxious power, or to correct and remove them. 
But these kinds of motion are considered as constitut- 
ing the disease. 

But the former is perhaps strictly the morbid state, 
while the latter is to be considered as the operation of 
the vis medicatrix naturce of salutary tendency, and 
which I shall hereafter call the reaction of the system. 

60. Upon the supposition that these two states take 
place in every paroxysm of fever, it will appear to be 
chiefly in the time of the hot stage that the reaction 
operates in removing the morbid state; and therefore as 



126 PRACTICE OF PHYSIC. 

this operation succeeds more or less quickly, the hot 
stage of paroxysms will be shorter or longer. But as 
the length of paroxysms depends chiefly upon the dura- 
tion of the hot stage, so the longer duration of this 
and of paroxysms, must be owing either to the obsti- 
nacy of resistance in the morbid state, or to the weak- 
ness of the salutary reaction; and it is probable that 
sometimes the one, and sometimes the other of these 
circumstances takes place. 

61. It seems to be only by the state of the spasm, 
that we can judge of the resistance of the morbid state 
of fever; and with respect to this spasm I observe, that 
either the cause exciting it may be different in different 
cases ; or, though the cause should be the same in 
different persons, the different degree of irritability in 
each may give occasion to a greater or lesser degree 
of spasm: and. therefore, the reaction in fever being 
given, the the continuance of the hot stage, and of the 
whole paroxysm, may be longer or shorter, according to 
the degree of spasm that has been formed. 

62. One cause of the obstinacy of spasm in fevers may 
be clearly perceived. - In inflammatory diseases, there 
is a diathesis phlogistica prevailing in the body, and this 
diathesis we suppose to consist in an increased tone of 
the whole arterial system. When, therefore, this dia- 
thesis accompanies fever, as it sometimes does, it may 
be supposed to give occasion to the febrile spasm's be- 
ing formed more strongly, and thereby to produce more 
protracted paroxysms. Accordingly we find, that all 
inflammatory fevers are of the continued kind; and that 
all the causes of the diathesis phlogistica have a ten- 
dency to change intermittent into continued fevers. 
Continued fevers, then, being often attended with the 
diathesis phlogistica, we conclude, th;>t, in many cases, 
this is the cause of their continued form. 



PRACTICE OF PHYSIC. \%% 

65. In many fevers, however, there is no evidence of 
any diathesis phlogistica being present, nor of any other 
cause of more considerable spasm; and, in such cases, 
therefore, we must impute the protraction of paroxysms, 
and the continued form of the fever, to the weakness of 
reaction. That this cause takes place, we conclude 
from hence, that, in many cases of fever, wherein the 
separate paroxysms are the longest protracted, and the 
most difficultly observed, we find the most considerable 
symptoms of a general debility: and therefore, we infer, 
that in such cases, the protracted paroxysms, and con- 
tinued form, depend upon a weaker reaction; owing 
either to the causes of debility applied having been of a 
more powerful kind, or from circumstances of the pa- 
tient's constitution favouring their operation. 

64. Upon these principles we make a step towards 
explaining in general, with some probability, the differ- 
ence of fevers; but must own, that there is much doubt 
and difficulty in applying the doctrine to particular 
«ases. It applies tolerably well to explain the different 
states of intermittents, as they are more purely such, 
or as they approach more and more to the continued 
form; but several difficulties still remain with respect to 
many circumstances of intermittents; and more still with 
respect to the difference of those continued fevers, which 
we have distinguished in our Nosology as different from 
intermittents, and as more specially entitled to the 
appellation of Continued, (see Syn. Nos. Meth. P. V. 
Ch. I. Sect. II.) and explained more fully above. 

65. From the view given (63. and 64.) of the causes of 
the protraction of paroxysms, and therefore of the form 
of continued fevers, strictly so called, it seems probable 
that the remote causes of these operate by occasioning 
either a phlogistic diathesis, or a weaker reaction ; 
for we can observe that the most obvious difference of 



128 PRACTICE OF PHYSIC. 

continued fevers depends upon the prevalence of one 
or other of these states. 

66. Continued fevers have been accounted of great 
diversity; but physicians have not been successful in 
marking these differences, or in reducing them to any 
general heads. The distinctions made by the ancients 
are not well understood; and, so far as either they or 
the modern nosologists have distinguished continued fe- 
vers by a difference of duration, their distinctions are 
not well founded, and do not apply in such a manner as 
to be of any use. We think it agreeable to observation, 
and to the principles above laid down, (63. 64.) to dis- 
tinguish continued fevers according as they show either 
an inflammatory irritation or a weaker reaction. 

67. This distinction is the same with that of fevers 
into the inflammatory and nervous; the distinction 
at present most generally received in Britain. To the 
first as a genus, I have given the name of Synochus; to 
the second, that of Typhus; and little studious whether 
these names be authorized by the ancient use of the same 
terms, 1 depend upon their being understood by the 
characters annexed to them in our Nosology, which I 
apprehend to be founded on observation. 

68. By these characters I think continued fevers may 
in practice be distinguished; and if that be the case, the 
principles above laid down will be confirmed. 

^9. Besides these differences of continued fever, now 
mentioned, I am not certain of having observed any 
other that can be considered as fundamental. But the 
most common forms of continued fevers, in this climate, 
seems to be a combination of these two genera; and I 
have therefore given such a genus place in our Noso- 
logy, under the title of Synochus. At the same time, I 
think that the limits between the Synochus and Typhus 
will be with difficulty assigned; and I api disposed to 



PRACTICE OF PHYSIC. 129 

believe, that the Synochus arises from the same causes 
as the Typhus, and is therefore only a variety of it. 

70. The Typhus seems to be a genus comprehend- 
ing several species. These, however, are not yet well 
ascertained by observation; and in the mean time we 
can perceive that many of the different cases observed, 
do not imply any specific difference, but seem to be 
merely varieties arising from a different degree of 
power in the cause, from different circumstances of the 
climate or season in which they happen, or from dif- 
ferent circumstances in the constitution of the persons 
affected. 

71. Some of the effects arising from these circum- 
stances require to be particularly explained. 

One is, an unusual quantity of bile appearing in the 
course of the disease. This abundance of bile may 
possibly attend some continued fevers, strictly so called; 
but, for the reasons above explained, it more com- 
monly attends intermittents, and we believe it might 
have been enumerated (29.) among the marks of dis- 
tinguishing the latter kind of fevers from the former. 
But though an unusual quantity of bile should appear 
with continued fevers, it is considered in this case, as 
in that of intermittents, to be a coincidence only, owing 
to the state of the season, and producing no different 
species or fundamental distinction, but merely a variety 
of the disease. I think it proper to observe here, that 
it is probable that the most part of the continued fevers 
named Bilious, have been truly such as belong to the 
section of Intermittents. 

72. Another effect of the circumstances occasionally 
varying the appearance of typhus, is a putrescent state 
of the fluids. The ancients, and likewise the moderns, 
who are in general much disposed to follow the former, 
have distinguished fevers, as putrid, and non-putrid: 

VOL. I. R 



130 PRACTICE OF PHYSIC. 

but the notions of the ancients, on this subject, were 
not sufficiently correct to deserve much notice; and it 
is only of late that the manner has been more accu- 
rately observed, and better explained. 

From the dissolved state of the blood, as it presents 
itself when drawn out of the veins, or as it appears from 
the red blood's being disposed to be effused and run off 
by various outlets, and from several other symptoms to 
be hereafter mentioned, I have now no doubt, how much 
soever it has been disputed by some ingenious men, 
that a putrescency of the fluids, to a certain degree, does 
really take place in many cases of fever. This putres- 
cency, however, often attends intermittent as well as 
continued fevers, and of the continued kind, both the 
synochus and typhus, and all of them in very different 
degrees; so that, whatever attention it may deserve in 
practice, there is no fixing such limits to it as to admit 
of establishing a species under the title of putrid. 

73. Beside differing by the circumstances already 
mentioned, fevers differ also by their being accompanied 
with symptoms which belong to diseases of the other 
orders of pyrexias. This sometimes happens in such a 
manner, as to render it difficult to determine which of 
the two is the primary disease. Commonly, however, it 
may be ascertained by the knowledge of the remote 
cause, and the prevailing epidemic, or by observing the 
series and succession of symptoms. 

74. Most of our systems of physic have marked, as 
a primary one, a species of fever under the title of hec- 
tic ; but as it is described, I have never seen it as a 
primary disease. I have constantly found it as a symp- 
tom of some topical affection, most commonly of an 
internal suppuration; and as such it shall be considered 
in another place. 

75. The distinction of the several cases of intermit- 



PRACTICE OF PHYSIC. 131 

tent fever I have not prosecuted here; both because we 
cannot assign the causes of the differences which ap- 
pear ; and because I apprehend that the differences 
which in fact occur may be readily understood from 
what is said above, (25. 26. and 21 '.) and more fully 
from our Methodical Nosology, Ch. I. Sect. I. 



CHAPTER I. 



OF THE REMOTE CAUSES OF FEVER. 

76. AS fever has been held to consist chiefly in an in- 
creased action of the heart and arteries, physicians have 
supposed its remote causes to be certain direct stimu- 
lants fitted to produce this increased action. In many 
cases, however, there is no evidence of such stimu- 
lants being applied; and in those in which they are ap- 
plied, they either produce only a temporary frequency 
of the pulse, which cannot be considered as a disease; 
or, if they do produce a permanent febrile state, it is by 
the intervention of a topical inflammation, which pro- 
duces a disease different from what is strictly called 
fever. (8.) 

77. That direct stimulants are the remote causes of 
fever, seems farther improbable; because the supposi- 
tion does not account for the phenomena attending the 
accession of fevers, and because other remote causes 
can with greater certainty be assigned.* 

* Having already dwelt somewhat in detail on this subject, we shall here 
simply remark, that we think the human mind can scarcely picture to itself 
an error surpassing, in grossness, that which derives febrile diseases from 
any thing but the action of stimulating causes. To attribute fever, which is 
an increased state of action in living matter, to the influence of a sedative, 



132 PRACTICE OF PHYSIC. 

78. As fevers are so generally epidemic, it is proba- 
ble, that some matter floating in the atmosphere, and 
applied to the bodies of men, ought to be considered as 
the remote cause of fevers: and these matters present 
in the atmosphere, and thus acting upon men, may be 
considered either as contagions, that is, effluvia aris- 
ing directly or originally from the body of a man under 
a particular disease, and exciting the same kind of dis- 
ease in the body of the person to whom they are applied; 
or miasmata, that is, effluvia arising from other sub- 
stances than the bodies of men, producing a disease in 
the person to whom they are applied. 

79 Conta§ronly|iave been supposed to be of great 
variety; and it is possible this may be the case; but that 
they truly are so, does not appear clearly from any 
thin^Sfeiv know at present. The genera and species of 
contagious diseases, of the class of the Pyrexiae, at pre- 
sent known, are in number not very great. They chiefly 
belong to the order of Fevers, to that of Exanthemata, 
or that of Profluvia. Whether there be any belonging 
to the order of Phlegmasia), is doubtful; and though 
there should, it will not much increase the number of 
contagious pyrexiae. Of the contagious exanthemata 
and profluvia, the number of species is nearly ascer- 
tained, and each of them is so far of a determined na- 
ture, that though they have now been observed and dis- 
tinguished for many ages, and in many different parts of 
the world, they have been always found to retain the 
same general character, and to differ only in circum- 
stances, that may be imputed to season, climate, and 
other external causes, or to the peculiar constitutions 
of the several persons affected. It seems, therefore, 

which means something calculated to diminish action, is precisely as absurd 
as it would be, to assign ice as the cause of burning, or flames of freezing. 
It is to deal not merely in paradoxes, but in contraries. 



PRACTICE OF PHYSIC. jgg 

probable, that in each of these species, the contagion 
is of one specific nature; and that the number of con- 
tagious exanthemata or profluvia is hardly greater than 
the number of species enumerated in the systems of 
nosology. 

80. If, while the contagious exanthemata and pro- 
fluvia are thus limited, we should suppose the conta- 
gious pyrexiae to be still of great and unlimited variety, 
it must be with respect to the genera and species of 
continued fevers. But if I be right in limiting, as I 
have done, the genera of these fevers, (67. — 70.) it 
will appear likely that the contagions which produce 
them are not of great variety: and this \**ill be much 
confirmed, if we can render it probable that there is 
one principal, perhaps one common, source of such 
contagion. 

81. To this purpose it is now well known that the 
effluvia constantly arising from the living human body, 
if long retained in the same place, without being dif- 
fused in the atmosphere, acquire a singular virulence; 
and, in that state, being applied to the bodies of men, be- 
come the cause of a fever which is highly contagious. 

The existence of such a cause is full) proved by the 
late observations on jail and hospital fevers: and that 
the same virulent matter may be produced in many 
other places, must be sufficiently obvious: and it is pro- 
bable that the contagion arising in this manner, is not, 
like many other contagions, permanent and constantly 
existing; but that, in the circumstances mentioned, it 
is occasionally generated. At the same time, the na- 
ture of the fevers from thence, upon different occasions, 
arising, renders it probable that the virulent state of 
human effluvia is the common cause of them, as they 
differ only in a state of their symptoms; which may 
be imputed to the circumstances of season, climate, 



134 ■ PRACTICE OF PHYSIC. 

&c. concurring with the contagion, and modifying its 
force.* 

82. With respect to these contagions, though we have 
spoken of them as of a matter floating in the atmos- 
phere, it is proper to observe, that they are never found 
to act but when they are near, to the sources from^ 
whence they arise; that is, either near to the bodies of 
men, from which they immediately issue; or near to 
some substances, which, as having been near to the 
bodies of men, are imbued with their effluvia, and in 
which substances these effluvia are sometimes retained 
in an active state for a very long time. 

The substances thus imbued with an active and in- 
fectious matter, may be called, Fomites; and it appears 
to me probable, that contagions, as they arise from fo- 
mites, are more powerful than as they arise immediately 
from the human body.f 

* Having nothing further which we think it necessary to add, we shall 
only here refer the reader to what we have already said on the subject of 
febrile contagion. 

f On the doctrine contained in this section is founded, in a great measure, 
the practice of quarantine. It is, therefore, of the utmost importance to 
commercial nations; and deserves, we think, a much more thorough and 
philosophical examination than it has ever undergone. 

Systems of quarantine were established in Europe, if not during the dark 
ages, at least long before the blaze of physical knowledge, which now 
exists, had opened on the world. , 

Since that period, the principles and opinions on which they were then 
founded have undergone no actual revision, and but little alteration. The 
interests of millions are suffered to be still under the control of laws and 
usages established at an era of great ignorance. This is a proceeding which 
is neither reasonable nor just ; nor is it honourable to the reputation of mo- 
dern times. 

In the countries of the old world, where the human mind is not a little 
restricted by the trammels of precedent, it is scarcely probable that this 
state of things will shortly undergo any material alteration. The son, there, 
feels himself almost compelled by pious duty, to walk in the path which his 
father has trodden. Hence the perpetuity of many an error. 

But, in the United States, the case is different. If we are, in relation to 
some points, without the lights of Europe to conduct us to what is right ; 
we are, with respect to others, free from those prejudices and restraints 



PRACTICE OF PHYSIC. 135 

83. Miasmata are next to be considered. These may 
arise from various sources, and be of different kinds; 
but we know little of their variety, or of their several 
effects. We know with certainty only one species of 
miasma, which can be considered as the cause of fe- 
ver; and, from the universality of this, it may be doubted 
if there be any other. 

84. This miasma, so universally the cause of fever, 
is that which arises from marshes or moist ground, 
acted upon by heat. So many observations have now 
been made with respect to this, in so many different re- 
gions of the earth, that there is neither any doubt of its 
being in general a cause of fevers, nor of its being very 
universally the cause of intermitting fevers in all their 
different forms. The similarity of the climate, season, 
and soil, in the different countries in which intermit- 
tents arise, and the similarity of the diseases, though 
arising in different regions, concur in proving, that there 
is one common cause of these diseases, and that this k 
the marsh miasma. 

What is the particular nature of this miasma, we 
know not, nor do we certainly know whether or not it 
differs in kind; but it is probable that it does not; and 



that might keep us in the wrong. Nor are these remarks inapplicable, as 
we think, to the present question. 

With us, systems of quarantine being of recent origin, the principles on 
which they are erected have not as yet become inflexible with age — have 
not degenerated into immutable canons. Would it not be well, therefore, 
while they still may be changed, to inquire, with more strictness than has 
been hitherto practised, into their truth and consequent fitness, to preserve 
the health of those whose commercial interests they so seriously affect ? 

Without asserting that the doctrine of Fomites is entirely unfounded, we 
feel persuaded that it is replete with error. 

Would it not be an act worthy of the government of the United States, to 
institute, by authority, a thorough revision of it ? We are convinced, that 
the science of legislation, a9 well as that ef medicine, would be benefited 
by the project 



136 PRACTICE OF PHYSK 

that it varies only in the degree of its power, or per- 
haps as to its quantity, in a given space.* 

85. It has been now rendered probable, that the re- 
mote causes of fevers (8.) are chiefly Contagions, or 
Miasmata, and neither of them of great variety. We have 
supposed that miasmata are the cause of intermittents, 
and contagions the cause of continued fevers, strictly so 
named; but we cannot with propriety employ these ge- 
neral terms. For, as the cause of continued fevers may 
arise from fomites, and may, in such cases, be called a 
Miasma; and as other miasmata also may produce con- 
tagious diseases ; it will be proper to distinguish the 
causes of fevers, by using the terms Human or Marsh 
Effluvia, rather than the general ones of Contagion or 
Miasma. 

86. To render our doctrine of fever consistent and 
complete, it is necessary to add here, that those remote 
causes of fever, hum^n and marsh effluvia, seem to be 
of a debiliating or sedative quality. They arise from a 
putrescent matter. Their production is favoured, and 
their power increased, by circumstances which favour 
putrefaction; and they often prove putrefactive ferments 
with respect to the animal fluids. As putrid matter, 
therefore, is always, with respect to animal bodies a 
powerful sedative, so it can hardly be doubted, that hu- 
man and marsh effluvia are of the same quality; and it 
is confirmed by this, that the debility which is always 
induced, seems to be in proportion to the other marks 
that appear of the power of those causes.f 

* We have long thought it probable, that the miasmata which produce 
yellow fever differ from those that give rise to intermittents, somewhat as 
the nitric does from the nitrous, and the sulphuric from the sulphureous 
acids. We know not on what other ground to attempt an explanation of the 
difference of their effects 

f For a refutation of the doctrine of putridity, as applied to the fluids of 



PRACTICE OF PHYSIC. 



137 



87. Though we have endeavoured to show that fevers 
generally arise from marsh or human effluvia, we can- 
not, with any certainty, exclude some other remote 
causes, which are commonly supposed to have at least 
a share in producing those diseases. And I proceed, 
therefore, to inquire concerning these causes; the first 
of which that merits attention, is the power of cold ap- 
plied to the human body. 

88. The operation of cold on a living body, is so dif- 
ferent in different circumstances, as to be of difficult 
explanation; it is here, therefore, attempted with some 
diffidence. 

The power of cold may be considered as absolute or 
relative. 

The absolute power is that by which it can diminish 
the temperature of the body to which it is applied. And 
thus, if the natural temperature of the human body is, 
as we suppose it to be, that of 98 degrees of Fahren- 
heit's thermometer;* every degree of temperature less 
than that may be considered as cold with respect to the 
human body; and, in proportion to its degree, will have 
a tendency to diminish the temperature of the body. 
But as the living human body has in itself a power of 
generating heat, so it can sustain its own proper heat to 
the degree above mentioned, though surrounded by air 
or other bodies of a lower temperature than itself; and 
it appears from observation, that, in this climate, air, or 

living animals, we cannot do better than refer the reader to an exce'len In- 
augural Dissertation, by Dr Seyben, published first in the year 179j and 
republished in a volume of Select Medical Theses, by Thomas and Williahl 
Bradford, for the year 1805. We shall, in the mean time, only obs< -u-, That 
a quantity of matter actually putrid, introduced into the blood-vessels of 
living animals, would prove as certainly and almost, as suddenly fatal as an 
equal amount of boiling water. 

* In every instance of our mentioning degrees of heat or cold, we shall 
mention them by the degrees in Fahrenheit's scale : and tiic expression of 
higher or lower shall always be according to that scale.— Cullen. 
VOL. I. S 



138 PRACTICE OF PHYSIC. 

other bodies applied to the living man, do not diminish 
the temperature of his body, unless the temperature of 
the bodies applied be below 62 degrees. From hence it 
appears, that the absolute power of cold in this climate, 
does not act upon the living human body, unless 
the cold applied be below the degree just now men- 
tioned. 

It appears also, that the human body's being sur- 
rounded by air of a lower temperature than itself, is ne- 
cessary to its being retained in its proper temperature 
of 98 degrees: for in this climate, every temperature of 
the air above 62 degrees, applied to the human body, 
though still of a lower temperature than itself, is found 
to increase the heat of it. And from all this it appears, 
that the absolute pow r er of cold with respect to the hu- 
man body, is very different trom what it is with respect 
to inanimate bodies.* 

89. The relative power of cold with respect to the 
living human body, is that power by which it produces 
a sensation of cold in it; and with respect to this, it is 
agreeable to the general principle of sensation, that the 
sensation produced, is not in proportion to the absolute 
force of impression, but according as the new impres- 
sion is stronger or weaker than that which had been 
applied immediately before. Accordingly, with respect 
to temperature, the sensation produced by any degree 
of this depends upon the temperature to which the body 
had been immediately before exposed; so that whatever 



* Our author's view of cold, as a cause of fever, is exceedingly laboured, 
obscure and unsatisfactory. That gent gives rise to fever on the same 
principles with every other. On the part to which it is applied, it pro- 
ducer an irritation. That irritation spreading by svmpathy from one organ 
or-subdivision of the system to another, forms a chain of morbid action in 
which the whole becomes ultimately involved A wound, the matter of 
smai 1 pox, marsh miusmaia, an excessive close of arsenic or corrosive subli- 
mate, and all other febrile causes act in the same way. 



PRACTICE OF PHYSIC. 139 

is higher than this feels warm, and whatever is lower 
than it, feels cold; and it will therefore happen that the 
opposite sensations of heat and cold may on different 
occasions arise from the same temperature, as marked 
by the thermometer. 

With respect to this, however, it is to be observed, that 
though every change of temperature gives a sensation 
of cold or heat as it is lower or higher than the tempera- 
ture applied immediately before, the sensation produced 
is, in different cases, of different duration. If the tem- 
perature at any time applied is under 62 degrees, every 
increase of temperature applied will give a sensa- 
tion of heat; but if the increase of temperature does 
notarise to 62 degrees, the sensation produced will not 
Continue long, but be soon changed to a sensation of 
cold. In like manner, any temperature, applied to the 
human body, lower than that of the body itself, gives a 
sensation of cold; but if the temperature applied does 
not go below 62 degrees, the sensation of cold will not 
continue long, but be soon changed to a sensation of 
heat. 

It will appear hereafter, that the effects of the sensa- 
tion of cold will be very different, according as it is 
more permauentor transitory. 

90. Having thus explained the operation of cold, as 
absolute or relative, with respect to the human body, I 
proceed to mention the general effects of cold upon it. 

1. Cold, in certain circumstances, has manifestly a 
sedative power. It can extinguish the vital principle en- 
tirely, either in particular parts, or in the whole body; 
and considering how much the vital principle of animals 
depends upon heat, it cannot be doubted that the power 
of cold is always more or less directly sedative. 

This effect may be said to take place from every de- 
cree of absolute cold ; and when the heat of the body 



140 PRACTICE OF PHYSIC. 

has upon any occasion been preternaturally increased, 
every lower temperature may be useful in diminishing 
the activity of the system; but it cannot diminish the 
natural vigour of the vital principle, till the cold applied 
is under 62 degrees; nor even then will it have this ef- 
fect, unless the cold applied be of an intense degree, or 
be applied for some length of time to a large portion of 
the body. 

2. It is equally manifest, that in certain circum- 
stances, cold proves a stimulus to the living body, and 
particularly to the sanguiferous system. 

It is probable, that this effect takes place in every 
case, in which the temperature applied produces a 
sensation of cold; and this, therefore, as depending en- 
tirely on the relative power of cold, will be in propor- 
tion to the change of temperature that takes place. 

It appears to me probable, that every change of tem- 
perature, from a higher to a lower degree, will prove 
more or less stimulant; excepting when the cold appli- 
ed is so intense, as immediately to extinguish the vital 
principle in the part. 

3. Besides the sedative and stimulant powers of 
cold, it is manifestly also a powerful astringent, causing 
a contraction of the vessels on the surface of the body, 
and thereby producing a paleness of the skin, and a 
suppression of perspiration; and it seems to have simi- 
lar effects when applied to internal parts. It is like- 
wise probable, that this constriction, as it takes place 
especially in consequence of the sensibility of the parts 
to which the cold is applied, will in some measure be 
communicated to other parts of the body; and that 
thereby the application of cold proves a tonic power 
with respect to the whole system. 

These effects of tonic and astringent power seem to 
take place both from the absolute and relative power 



PRACTICE OF PHYSIC. 



141 



of cold; and therefore every application of it, which 
gives a sensation of cold, is, in its first effect, both as- 
tringent and stimulant, though the former may be often 
prevented from being either considerable or perma- 
nent, when the latter immediately lakes place. 

91. It will be obvious, that these several effects of 
eold cannot all take place at the same time, but may 
in succession be variously combined. The stimulant 
power taking place obviates the effects, at least the 
permanency of the effects, that might otherwise have 
arisen from the sedative power. That the same sti- 
mulant power prevents these from the astringent, I have 
said above; but the stimulant and tonic powers of cold 
are commonly, perhaps always, conjoined. 

92. These general effects of cold now pointed out 
are sometimes salutary, frequently morbid; but it is the 
latter only I am to consider here, and they seem to be 
chiefly the following. 

1. A general inflammatory disposition of the system, 
which is commonly accompanied with Rheumatism, or 
other Phlegmasias. 

2. The same inflammatory disposition accompanied 
with Catarrh. 

3. A Gangrene of particular parts. 

4. A Palsy of a single member. 

5. A Fever, or Fever strictly so called (8.) which 
it often produces by its own power alone, but more 
eommonly it is only an exciting cause of fever by con- 
curring with the operation of human or marsh effluvia. 

93. Cold is often applied to the human body with- 
out producing any of these morbid effects, and it is 
difficult to determine in what circumstances it espe- 
cially operates in producing them. It appears to me, 
that the morbid effects of cold depend partly upon cer- 



112 PRACTICE OF PHYSIC. 

tain circumstances of the cold itself, and partly on cer- 
tain circumstances of the person to whom it is applied. 

94. The circumstances of the cold applied, which 
seem to give it effect, are, 1. The intensity or degree 
of the cold; 2. The length of time during which it is 
applied; 3. The degree of moisture at the same time ac- 
companying it; 4. Its being applied by a wind or cur- 
rent of air; 5. Its being a vicissitude, or sudden and 
considerable change of temperature, from heat to cold. 

95. The circumstances of persons rendering them 
more liable to be affected by cold, seem to be, 1. The 
weakness of the system, and particularly the lessened 
vigour of the circulation, occasioned by fasting, by 
evacuations, by fatigue, by a last night's debauch, by 
excess in venery, by long watching, by much study, by 
rest immediately after great exercise, by sleep, and by 
preceding disease. 2. The body, or its parts, being de- 
prived of their accustomed coverings. 3. One part of 
the body being exposed to cold, while the rest is kept 
in its usual or a greater warmth. 

96. The power of these circumstances (95) is de- 
monstrated by the circumstances enabling persons to 
resist cold. These are a certain vigour of constitution, 
exercise of the body, the presence of active passions, 
and the use of cordials. 

Besides these, there are other circumstances which, 
by a different operation, enable persons to resist cold 
acting as a sensation; such as, passions engaging a close 
attention to one object, the use of narcotics, and that 
state of the body in which sensibility is greatly dimi- 
nished, as in maniacs. To all which is to be added, 
the power of habit with respect to those parts of the 
body to which cold is more constantly applied, which 
both diminishes sensibility and increases the power of 
the activity generating heat. 



PRACTICE OF PHYSIC. 143 

97. Besides cold, there are other powers that seem 
to be remote causes of fever; such as fear, intempe- 
rance in drinking, excess in venery, and other circum- 
stances, which evidently weaken the system. But 
whether any of these sedative powers be alone the re- 
mote cause of fever, or if they only operate either as 
concurring with the operation of marsh or human efflu- 
via, or as giving an opportunity to the operation of 
cold, are questions not to be positively answered: they 
may possibly of themselves produce fever, but most fre- 
quently they operate as concurring in one or other of 
the ways above mentioned. 

98. Having now mentioned the chief of the remote 
causes of fevers, it may be further observed, that 
these will arise more or less readily, according as mi- 
asmata and contagions are more or less prevailing 
and powerful, or as these are more or less favoured 
by the concurrence of cold and other sedative powers. 



chapter v. 

OF THE PROGNOSIS OF FEVERS. 

99. AS fevers (by 60.) consist of both morbid and sa- 
lutary motions and symptoms, the tendency of the dis- 
ease to a happy or fatal issue, or the prognostic in fe- 
vers, has been established by marking the prevalence of 
the morbid or of the salutary symptoms; and it might 
be properly so established, if we could certainly distin- 
guish between the one and the other of these kind of 
symptoms: but the operation of the reaction, or salu- 
tary efforts of nature in curing fevers, is still involved 
m so much obscurity, that I cannot explain the several 



144 PRACTICE OF PHYSIC. 

symptoms of it so clearly as to apply them to the esta- 
blishing prognostics; and this, I think, may be done 
better, by marking the morbid symptoms which show 
the tendency to death in fevers.* 

100. This plan of the prognostics in fevers must pro- 
ceed upon our knowledge of the causes of death in ge- 
neral, and in fevers more particularly. 

The causes of death, in general, are either direct or 
indirect. 

The first are those which directly attack and destroy 
the vital principle, as lodged in the nervous system; or 
destroy the organization of the brain immediately ne- 
cessary to the action of that principle. 

The second, or the indirect causes of death, are those 
which interrupt such functions as are necessary to the 
circulation of the blood, and thereby necessary to the 
due continuance and support of the vital principle-! 

101. Of these general causes, those which operate 
more particularly in fevers seem to be, first, The vio- 
lence of reaction; which, either by repeated violent ex- 

* Although it may be, and very probable is true, that all fevers consist of 
a mixture of morbid and salutary motions, it is equally so that we have not 
yet learnt to discriminate with accuracy between them. Nothing 1 would be 
more dangerous, therefore, than an attempt to establish our prognosis on 
that ground. 

Indeed the doctrine or rather practice of prognosis is one in which all 
practitioners, but especially young ones, ought to deal with the utmost cau- 
tion. Although it is both natural and right for them to exercise their pene- 
tration and sagacity in endeavouring to form some opinion as to the proba- 
ble termination of every case of disease, prudence and a due regard to their 
own reputation require of them not to be very liberal in the communication 
of that opinion to others. One false prediction may do them an injury which 
ten correct ones will not remedy. Let their prognosis, therefore, rest with 
themselves, until the case be so clear that they cannot be deceived. 

j- Under this head our author might have added another set of causes, viz. 
those which deeply disorder the functions of the stomach. In the malignant bili- 
ous or yellow fever, no symptom is of more fatal prognosis than an obsji- 
nate vomiting. Indeed such is the importance of the stomach, as a seat and 
centre of sympathy, that in every case wherein it is very seriously affected, 
life must be considered as somewhat endangered. 



PRACTICE OF PHYSIC. 145 

citements, destroys the vital power itself; or, by its 
violence, destroys the organization of the brain neces- 
sary to the action .of that power; or, by the same vio- 
lence, destroys the organization of the parts more im- 
mediately necessary to the circulation of the blood. 

Secondly, The cause of death in fevers may be a 
poison, that is, a power capable of destroying the vital 
principle; and this poison may be either the miasma 
or contagion which was the remote cause of the fever, 
or it may be a putrid matter generated in the course of 
the fever. In both cases, the operation of such a power 
appears either as acting chiefly on the nervous system, 
inducing the symptoms of debility; or, as acting upon 
the fluids of the body, inducing a putrescent state in 
them. 

102. From all this it appears, that the symptoms 
showing the tendency to death in fevers, may be disco- 
vered by their being either the symptoms 

Of violent reaction; 
Of great debility^; 

Or, of a strong tendency to putrefaction in the fluids. 
And upon this supposition, I proceed now to mark 
those symptoms more particularly.* 

103. The symptoms which denote the violence of re- 
action, are, 1. The increased force, hardness, and fre- 
quency of the pulse. 2. The increased beat of the 
body. 3. The symptoms which are the marks of a 
general inflammatory diathesis, and more especially of 
a particular determination to the brain, lungs, and other 
important viscera. 4. The symptoms which are the 
marks of the cause of violent reaction; that is, of a 

* It is much to be regretted that this doctrine of putrescency corrupts 
the whole of our author's reasonings. Fortunately, however, it does not in* 
juriously affect his practice — or, if at all, but very slightly. The remedies 
which he administers to prevent or correct putrefaction, are such,' in gene- 
ral, as, on sound principles, the case requires. 
VOL. I. T 



146 PRACTICE OF PHYSIC. 

strong stimulus applied, or of a strong spasm formed, 
the latter appearing in a considerable suppressionof 
the excretions.* 

101. The symptoms which denote a great degree of 
debility, are, 

In the animal functions: I. The weakness of the 
voluntary motions; II. The irregularity of the volun- 
tary motions, depending on their debility; III. The 
weakness of sensation; IV. The weakness and irregu- 
larity of the intellectual operations. 

In the vital functions: I. The weakness of the 
pulse; II. The coldness and shrinking of the extremi- 
ties; III. The tendency to a detiquium animi in an erect 
posture; IV. The weakness of respiration. 

In the natural functions: I. The weakness of the 
stomach, as appearing in anorexia, nausea, and vomit- 
ing; II. Involuntary excretions, depending upon a palsy 
of the sphincters; III. Difficult deglutition, depending 
upon a palsy of the muscles of the fauces. 

105. Lastly, The symptoms denoting the putrescent 
state of the fluids, are, 

I With respect to the stomach; the loathing of ani- 
mal food, nausea, and vomiting, great thirst, and a de- 
sire of acids. 

II. With respect to the fluids; 1. The blood drawn 
out of the veins not coagulating as usual; 2. Hemor- 
rhagy from different parts, without marks of increased 
impetus; 3 Effusions under the skin or cuticle, form- 
ing petechias, macula?, and vibices; 4. Effusions of a 
yellow serum under the cuticle. 

* Our author's enumeration of the symptoms on which he foun<ls his prog- 
nosis in fevers, although it might, we think, be somewhat extended, is one 
of the most judicious portions of his work. As far as it goes, it is the re- 
sult of correct observation, and a profound knowledge of t!ie human sys- 
tem It merits, therefore, the particular attention of those who are in pur- 
suit of practical medicine. 



PRACTICE OF PHYSIC. 1 47 

IN. With respect to the state of the excretions; fe- 
tid breath, frequent, loose and fetid stools, high coloured 
turbid urine, fetid sweats, and the fetor and livid colour 
of blistered places. 

IV. The cadaverous smell of the whole body. 

106. These several symptoms have very often, each 
of them singly, a share in determining the prognostic; 
but more especially by their concurrence and combina- 
tion with one another; particularly those of debility with 
those of putrescency. 

107. On the subject of the prognostic, it is proper to 
observe, that many physicians have been of opinion 
there is something in the nature of fevers which gene- 
rally determines them to be of a certain duration; and 
therefore that their terminations, whether salutary or 
fatal, happen at certain periods of the disease rather 
than at others. These periods are called the critical 
days; carefully marked by Hippocrates and other an- 
cient physicians, as well as by moderns of the greatest 
eminence in practice; whilst at the same time many 
other moderns of no inconsiderable authority, deny 
their taking place in the fevers of these northern re- 
gions which we inhabit* 

* In addition to tlie professor's remarks on the Hippocratic doctrine of 
critical days, which, in the main, we believe, has a foundation in nature, 
we shall only observe, that we think there is scarcely a position in medi- 
cine more clear!} established, than that regular intermitients are marked by 
hebdomadal periods If attended to at the commencement, they may be 
brought to& perfect termmation, almost with certainty, at the end o! a week — 
seldom, perhaps, in a much shorter period— and, if any improper exposure 
be sustained by the patients, they will be likely to recur about the expira- 
tion of the next or the second week. As an excellent practical rule, there- 
fore, let preventive remedies be employed until the end of a fortnight afcer 
the termination of these diseases. 

The best preventives are, suitable clothing", a careful avoidance of excit- 
ing causes, a generous diet, regulated, however, by the state of the system, 
and the use of the bark, or strong infusions of chamomile, centaury, quassia, 
or other bitters. 



148 PRACTICE OF PHYSIC. 

108. I am of opinion that the doctrine of the ancients, 
and particularly that of Hippocrates, on this subject, 
was well founded; and that it is applicable to the fevers 
of our climate. 

109. I am of this opinion, first, Because I observe 
that the animal economy, both from its own constitu- 
tion, and from habits which are easily produced in it, is 
readily subjected to periodical movements. Secondly, 
Because, in the diseases of the human body, I observe 
periodical movements to take place with great constancy 
and exactness; as in the case of intermittent fevers, and 
many other diseases, 

110. These considerations render it probable, that 
exact periodical movements may take place in continued 
fevers; and I thiuk there is evidence of such movements 
actually taking place. < 

111. The critical days, or those on which we suppose 
the termination of continued fevers especially to happen, 
are, the third, fifth, seventh, ninth, eleventh, fow teenth y 
seventeenth, and twentieth. We mark none beyond this 
last; because, though fevers ate sometimes protracted 
beyond this period, it is, however, more rarely; so that 
there are not a sufficient number of observations to 
ascertain the course of them; and further, because it is 
probable that, in fevers long protracted, the movements 
become less exact and regular, and therefore less easily 
observed. 

112. That the days now mentioned are the critical 
days, seems to be proved by the particular facts which are 
found in the writings of Hippocrates. From these facts, 
as collected from the several writings of that author by 
M. de Haen, it appears, that of one hundred and sixty- 



A due attention to these precautions could not fail to render relapses much 
less frequent than they usually are. 



PRACTICE OF PHYSIC. 149 

three instances of the termination of fevers, which hap- 
pened on one or other of the first twenty days of the 
disease, there are one hundred and seven, or more than 
two-thirds of the whole number, which happened on 
one or other of the eight days above mentioned; that 
none happened on the second or thirteenth day, and 
upon the eighth, tenth, twelfth, fifteenth, sixteenth, 
eighteenth, and nineteenth, there are but eighteen in- 
stances of termination, or one ninth of the whole. 

113. As the terminations which happen on the seven 
days last mentioned, are, upon the whole, few; and, up- 
on any one of them, fewer than those which happen on 
any one of our supposed critical days; so there are there- 
fore nine days which may be called non-critical; 
while, on the other hand, the many terminations which 
happened on the seventh, fourteenth, and twentieth 
days, afford a proof both of critical days in general, and 
that these are the chief of them. Hereafter I shall men- 
tion an analogy that renders the power of the other 
critical days sufficiently probable. 

114. It appears further, that as, of the terminations 
which were final and salutary, not a tenth part hap- 
pened on the non-critical days; and of the terminations 
which were final and fatal, though the greater number 
happened on the critical days, yet above a third of them 
happened on the non-critical; so it would appear that 
the tendency of the animal economy is to observe the 
critical days, and that it is by the operation of some 
violent and irregular cause that the course of things is 
sometimes turned to the non-critical. 

1 15. What has been said gives sufficient ground for 
presuming, that it is the general tendency of the animal 
economy to determine the periodical movements in fe- 
vers to be chiefly on the critical days. At the same time, 
we must acknowledge it to be a general tendency only; 



150 PRACTICE OF PHYSIC. 

and that in particular cases, many circumstances may 
occur to disturb the regular course of it. Thus, though 
the chief and more remarkable exacerbations in con- 
tinued fevers happen on the critical days, there are truly 
exacerbations happening every day; and these, from 
certain causes, may become considerable and critical. 
Further, though intermittent fevers are certainly very 
strongly determined to observe a tertian or quartan 
period, we know there are certain circumstances which 
prevent them from observing these periods exactly, and 
which render them either anticipating or postponing so 
much, that the days of paroxysms come to be quite 
changed; and it is allowable to suppose that the like 
may happen with respect to the exacerbations of con- 
tinued fevers, so as thereby to disturb the regular ap- 
pearance of critical days. 

A particular instance of this occurs with respect to 
the sixth day of fevers. In the writings of Hippocrates, 
there are many instances of terminations happening on 
the sixth day; but it is not therefore reckoned among 
the critical days; for of the terminations happening on 
that day, there is not one which proves finally of a 
salutary kind; the greater number are fatal; and all the 
rest are imperfect, and followed with a relapse. All 
this shows, that some violent cause had, in these cases, 
produced a deviation from the ordinary course of na- 
ture; that the terminations on the sixth day are nothing 
more than anticipations of the seventh, and therefore a 
proof of the power of this last. 

116. The doctrine of critical days has been much 
embarrassed by some dissonant accounts of it, which 
appear in the writings imputed to Hippocrates. But this 
may be justly accounted for from these writings being 
truly the works of different persons, and from the most 
genuine of them having suffered many corruptions; so 



PRACTICE OF PHYSIC. 15] 

that, in short, every thing which is inconsistent with the 
facts above laid down, may be ascribed to one or other 
of these causes. 

117. This, further, has especially disturbed the doc- 
trine of critical days, that Hippocrates himself attempt- 
ed, perhaps too hastily, to establish general rules, and to 
bring the doctrine to a general theory, drawn from Py- 
thagorean opinions concerning the power of numbers. 
It is this which seems to have produced the idea of odd 
days, and of a quaternary and septenary period, doc- 
trines which appear so often in the writings of Hippo- 
crates. These, however, are inconsistent with the facts 
above laid down; and, indeed, as Asclepiades and Cel- 
sus have observed, are inconsistent with one another. 

118. Upon the whole, therefore, it is apprehended, 
that the critical days above assigned are truly the criti- 
cal days of Hippocrates, and may be consistently ex- 
plained in the following manner. 

119. From the universality of tertian or quartan pe- 
riods in intermittent fevers, we cannot doubt of there 
being, in the animal economy, a tendency to observe 
such periods; and the critical days above mentioned 
are consistent with this tendency of the economy, as all 
of them mark either tertian or quartan periods. These 
periods, however, are not promiscuously mixed, but 
occupy constantly their several portions in the progress 
of the disease; so that, from the beginning to the 
eleventh day a tertian period takes place, and from the 
eleventh to the twentieth, andperhaps longer, a quartan 
period is as steadily observed. 

120. What determines the periods to be changed 
about the eleventh day, we have not clearly perceived; 
but the fact is certain: for there is no instance of any 
termination on the thirteenth, that is, the tertian period 
next following the eleventh; whereas upon the lour- 



152 PRACTICE OF PHYSIC. 

teenth, seventeenth, and twentieth, which mark quartan 
periods, there are forty-three instances of terminations, 
and six only on all the intermediate davs between these. 
This prevalence of a quartan period leaves no room 
for doubting that the twentieth, and not the twenty-first, 
is the critical day marked by Hippocrates, though the 
last is mentioned as such in the common edition of the 
Aphorisms, taken from an erroneous manuscript, which 
Celsus also seems to have copied. 

121. A consistency with the general tendency of the 
system renders the series of critical days we have men- 
tioned, probably the true one; and the only remaining 
difficulty in finding what we have delivered to be the 
same with the genuine doctrine of Hippocrates, is the 
frequent mention of the fourth as a critical day. 

It is true there are more instances of terminations 
happening on this day, than on some of those days we 
have asserted to be truly critical: but its inconsistency 
with the more general tendency, and some other consi- 
derations, lead us to deny its being naturally a critical 
day; and to think that the instances of terminations, 
which have really occured on the fourth day, are to be 
reckoned among the other irregularities that happen in 
this matter. 

122. I have thus endeavoured to support the doctrine 
of critical days, chiefly upon the particular facts to be 
found in the writings of Hippocrates: And although I 
might also produce many other testimonies of both an- 
cient and modern times, yet it must be owned, that some 
of these testimonies may be suspected to have arisen 
rather from a veneration of Hippocrates, than from ac- 
curate observation. 

123. With respect to the opinions of many moderns 
who deny the prevalence of critical days, they are to be 
little regarded, for the observation of the course of con- 



PRACTICE OF PHYSIC. 15$ 

tinned r evers is known to be difficult and fallacious; and 
therefore the regularity of that course may have often 
escaped inattentive and prejudiced observers. 

124 Our own observations amount to this, That fe- 
vers with moderate symptoms, generally the cases of 
the synocha, frequently terminate in nine days, or sooner, 
and very constantly upon one or other of the critical days 
which fall within that period: but it is very rare, in this 
climate, that cases of either the typhus or synochus ter- 
minate before the eleventh day: and when they do ter- 
minate on this day, it is for the most part fatally. When 
they are protracted beyond this time, I have very con- 
stantly found, that their terminations were upon the 
fourteenth, seventeenth, or twentieth day. 

In such cases, the salutary terminations are seldom 
attended with any considerable evacuation. A sweating 
frequently appears, but is seldom considerable; and I 
have hardly ever observed critical and deci ive termina- 
tions attended with vomiting, evacuations by stool, or 
remarkable changes in the urine. The solution of the 
disease is chiefly to be discerned from some return of 
sleep and appetite, the ceasing of delirium, and an abate- 
ment of the frequency of the pulse. By these symptoms 
we can often mark a crisis of the disease: but it seldom 
happens suddenly and entirely; and it is most commonly 
from some favourable symptoms occurring upon one 
critical day, that we can announce a more entire solu- 
tion upon the next following. 

Upon the whole, I am persuaded, that if observations 
shall be made with attention, and without prejudice, I 
shall be allowed to conclude with the words of the 
learned and sagacious Ganbius, " Fallor, ni sua consti- 
terit Hippocrati auctoritas, Galeno fides, nature 
virtus et ordo." 

vol. i. u 



154 PRACTICE OF PHYSIC. 



CHAPTER VI.* 
OF THE METHOD OF CURE IN FEVERS. 
Sect. I. — Of the Cure of Continued Fevers. 

125. AS it is allowed, that in every fever which has its 
full course, there is an effort of nature of a salutary 
tendency, it might be supposed that the cure of fevers 
should be left to the operations of nature, or that our 
art should be only directed to support and regulate these 
operations, and that we should form the indications ac- 
cordingly. This plan, however, I cannot adopt, because 
the operations of nature are very precarious, and not so 
well understood as to enable us to regulate them pro- 
perly. It appears to me, that trusting to these opera- 
tions has often given occasion to a negligent and inert 
practice; and there is reason to believe, that an attention 
to the operations of nature may be often superseded 
by art.f 

* This chapter being intended to develop the general principles of prac- 
tice in febrile diseases, is one of the most important in the whole work From 
the pupil therefore, who is true to himself, it will receive a corresponding 
degree of attention. If not actually committed to memory, it should, at 
least, be studied with such labour and fidelity of research, that every prin- 
ciple of it may be accurately retained. 

| Although it is doubtless true, that the practitioner of medicine should 
be cautious not to trust too far to the operations of Nature, he may notwith- 
standing derive, at times, from that source, some of his most important indi- 
cations of cure. Instead of neglecting Nature, therefore, or in the empbati- 
cal language of a late medical leacher, " turning her out of doors," let him 
patiently and studiously watch her movements. 

In the commencement of an epidemic disease, she is sometimes his best, if 
not his only instructor. She makes an obvious effort to relieve the sick 
through some of the emunctork s He will be safe, for the most part; in fol- 
lowing her example. If the effort be made through the bowels, let him 



PRACTICE OF PHYSIC. 155 

126. The plan which to me appears to be most suita- 
ble is that which forms the indications of cure upon the 
view of obviating the tendency to death ; while at the 
same time the means of executing these indications are 
directed by a proper attention to the proximate cause 
of fevers. 

Upon this plan, in consequence of what has been laid 
down above on the subject of the prognostic, we form 
three general indications in the cure of continued fe- 
vers; and the one or other of these is to be employed 
according as the circumstances* of the fever (102.) 
shall direct. 

The first therefore is, To moderate the violence of re- 
action. 

The second is, To remove the causes or obviate the 
effects of debility. And, 

The third is, To obviate or correct the tendency of the 
fluids to putrefaction. 

127. The first indication may be answered, that is, 
the violence of reaction may be moderated, 

1. By all those means which diminish the action of 
the heart and arteries. 

2. By those means which take off the spasm of the 
extreme vessels, which we suppose to be the chief cause 
of violent reaction. 



purge; if through the skin, let him encourage a perspiration ; and if, as is 
sometimes the case, hemorrhagies appear in an early stage of the disease, 
venesection may be generally employed with advantage. 

Some of the physicians of Philadelphia must well recollect to have seen 
these positions abundantly confirmed in the epidemic fever which they so 
often witnessed between the years 1793 and 1805. 

A strong desire for wine and acids, in cases where those articles are 
essential as remedies, constitutes another instance in which Nature assists the 
practitioner in forming correct indications of cure. 

That physician who, in the treatment of diseases, renders his labours at 
all tirae» faithfully ancillary to those of nature, acquits himself of a very im- 
portant branch of his duty. 



156 PRACTICE OF PHYSIC. 

128. The action of the heart and arteries may be 
diminished, 

1. By avoiding or moderating those irritations, which, 
in one degree or other, are almost constantly applied to 
the body. 

2. By the use of certain sedative powers. 

3. By diminishing the tension and tone of the arterial 
system. 

129. The irritations (128. 1.) almost constantly ap- 
plied, are the impressions made upon our senses; the 
exercise of the body and mind; and the taking in of 
aliments. The avoiding these as much as possible, or 
the moderating their force, constitute what is rightly 
called the antiphlogistic regimen, proper to be em- 
ployed in almost every continued fever. 

130. The conduct of this regimen is to be directed 
by the following rules and considerations.* 

* In conducting the sick through a strict course of antiphlogistic regimen, 
the (wo greatest difficulties with which physicians have to contend, is a de- 
sire in their patients to take improper exercise, and in their nurses and 
attendants that they should take improper food. The latter, in particular, 
is oftentimes a source of great mischief. In febrile diseases of high action, 
nothing should be received into the stomach that is not in a liquid state ; as 
sago, panado, tapioca, water gruel, or some such mild vegetable nutriment. 
Solid food is totally inadmissible. The stomach being unable to master and 
digest it, it acts on that organ like an extraneous and insoluble substance, 
producing in it great irritation, which, through the medium of sympathy, is, 
in a short time, communicated to the whole system. In cases where conva- 
lescence had already commenced, a few mouthfuls of solid food, particularly 
animal food, has frequently produced relapses dangerous aHd even fatal. 

The only drinks that are compatible with the antiphlogistic regimen, are 
<Hich as are thin, mild, and diluting. Simple water, toast water, lemonade, 
lintseed tea, barley water, apple water, a solution of gum arabic in water, 
currant jelly dissolved in water, with othersimilar articles, are most suitable. 

Where the object is to remove severe thirst, which, in cases of fever, ope- 
rates as a powerful and injurious irritant, acidulated drinks are most effica- 
cious. In preparing them the native vegetable acids should be preferred. 
Vinegar and the mineral acids act too powerfully on the stomach, and are, 
therefore, improper. In febrile cases of violent reaction, we think them 
always injurious. In typhus they are more admissible. The juice of limes and 
lemons, oranges and apples, currants and grapes, is grateful and beneficial. 



PRACTICE OF PHYSIC. 157 

1. Impressions on the external senses, as being stimu- 
lant to the system, and a chief support of its activity, 
should be avoided as much as possible; those especially 
of more constant application, those of a stronger kind, 
and those which give pain and uneasiness. 

No impression is to be more carefully guarded against 
than that of external heat; while at the same time every 
other means of increasing the heat of the body is to be 
shunned. Both these precautions are to be observed as 
soon as the hot stage is fully formed, and to be attended 
to during its continuance; excepting in certain cases, 
where a determination to sweating is necessary, or 

It is, in many instances, of great importance to remove the irritation of 
retained feces, by injections, as our author proposes, rather than by purga- 
tives The latter disorder the stomach, and, through that medium, the whole 
system ; while the former merely carry off the offending matter, without 
producing any distressing or injurious commotion. Besides, injections by 
being well prepared and skillfully administered, may be made to operate 
with great force. It is not true, as is usually observed, that they act only on 
the lower intestines. Under proper management, and when frequently 
repeated, they evacuate effectually the whole canal. 

Mild injections may consist of tepid water alone, milk and water, or mo- 
lasses and water, either with or without the addition of a little sweet oil. To 
render them more active, add a table spoonful or two of muriate of soda, or 
sulphate of soda, and castor oil instead of sweet oil. The amount of the oil 
may be about two ounces ; and of the whole injection, if for an adult, at 
least a pint, or even more, in case a powerful effect be required. 

From twelve to fifteen or twenty grains of tartarized antimony, dissolved in 
a suitable medium and thrown up the rectum, operate very powerfully in 
evacuating the bowels. This preparation extends its influence to the sto- 
mach itself. In cases of colic, it is sometimes very effectual in dissolving the 
spasm which prevents the peristaltic motion of the intestines. 

Injections of co Id -water have been found to be productive of a similar 
effect. 

But, perhaps the most powerful injection that can be prepared is a decoc- 
tion of tobacco. Into a quart of water put a drachm of the leaves of that 
plant, and boil it down to a pint. This forms an injection which scarcely 
any obstinacy of stricture or constipation can resist. 

In general, moderately stimulating injections are most suitable in cases of 
fever. The more drastic ones are rarely called for except in colic, stran- 
gulated hernia, and other instances of obstinate costivene-ss or dangerous 
spasm. 



158 PRACTICE OF PHYSIC. 

where the stimulant effects of heat may be compensated 
by circumstances which determine it to produce a re- 
laxation and revulsion. 

2. All motion of the body is to be avoided, especially 
that which requires the exercise of its own muscles; 
and that posture of the body is to be chosen which em- 
ploys the fewest muscles, and which keeps none of 
them long in a state of contraction. Speaking, as it 
accelerates respiration, is particularly to be refrained 
from. 

It is to be observed, that every motion of the body 
is the more stimulant, in proportion as the body is 
weaker. 

3. The exercise of the mind also is a stimulus to the 
body; so that all impressions, which lead to thought, 
and those especially which may excite emotion or pas- 
sion, are to be carefully shunned. 

With respect to avoiding impressions of all kinds, an 
exception is to be made in the case of a delirium com- 
ing on, when the presenting of accustomed objects may 
have the effect of interrupting and diverting the irregu- 
lar train of ideas then arising in the mind. 

4. The presence of recent aliment in the stomach 
proves always a stimulus to the system, and ought 
therefore to be as moderate as possible. A total absti- 
nence for some time may be of service; but as this can- 
not be long continued with safety, we must avoid the 
stimulus of aliment, by choosing that kind which gives 
the least. We suppose that alimentary matters are 
more stimulant, according as they are more alkalescent; 
and this leads to avoid all animal, and to use vegetable 
food only. 

As our drinks also may prove stimulant, so all aro- 
matic and spirituous liquors are to be avoided; and in 
answering the present indication, all fermented liquors, 



PRACTICE OF PHYSIC. 



159 



excepting those of the lowest quality, are to be ab- 
stained from. 

131. Besides these stimulant powers more constantly 
applied, there are others which, although occasionally 
only, yet, as commonly accompanying fevers, must be 
attended to and removed. 

One is, the sense of thirst, which, as a powerful sti- 
mulus, ought always, in one way or other, to be removed. 

Another stimulus frequently arises from crudities, or 
corrupted humours in the stomach; and it is to be re- 
moved by vomiting, by dilution, or by the use of acids. 

A third stimulus often arises from the preternatural 
retention of fasces in the intestines, and ought to be 
removed by frequent laxative glysters. 

A fourth stimulus to be constantly suspected in fe- 
vers, is a general acrimony of the fluids, as produced 
by the increase of motion and heat, joined with an in- 
terruption of the excretions. This acrimony is to be 
obviated or removed by the taking in of large quanti- 
ties of mild and antiseptic liquors. 

132. The avoiding of irritation in all these particu- 
lars, (130. and 131.) constitutes the antiphlogistic regi- 
men absolutely necessary for moderating the violence of 
reaction; and, if I mistake not, is proper in almost 
every circumstance of continued fevers; because the 
propriety and safety of employing stimulants is often 
uncertain; and because several of those above men- 
tioned, beside their stimulant powers, have other quali- 
ties by which they may be hurtful. 

It appears to me, that the supposed utility of stimu- 
lants, in certain cases of fever, has often arisen from a 
mistake in having ascribed to their stimulant, what 
reallv depended upon their antispasmodic power. 

133. A second head of the means (128. 2.) for mo- 
derating the violence of reaction, comprehends certain 



160 PRACTICE OF PHYSIC. 

sedative powers, which may be employed to diminish 
the activity of the whole body, and particularly that of 
the sanguiferous system. 

Theirs* of these to be mentioned is the application 
of cold. 

Heat is the chief support of the activity of the animal 
system; which is therefore provided in itself with a 
power of generating heat. But, at the same time, we ob- 
serve, that this would go to excess, were it not con- 
stantly moderated by a cooler temperature in the sur- 
rounding atmosphere. When, therefore, that power of 
the system generating heat is increased, as is commonly 
the case in fevers, it is necessary not only to avoid all 
means of increasing it further, but it seems proper also 
to apply air of a cooler temperature; or at least to apply 
it more entirely and freely, than in a state of health. 

Some late experiments in the small pox and in con- 
tinued fevers, show that the free admission of cool air 
to the body, is a powerful remedy in moderating the 
violence of reaction; but what is the mode of its opera- 
tion, to what circumstances of fever it is peculiarly 
adapted, or what limitations it requires, I shall not ven- 
ture to determine, till more particularly instructed by 
further experience.* 



* Cold, as an antiphlogistic remedy, should never be applied in so high a 
degree as to produce a disagreeable sensation. If it be, it will certainly irri- 
tate and prove injurious. When so employed as gradually to evacuate calo- 
ric from the system, and remove the distressing sensation of heat, it does 
good. 

In the treatment of f brile diseases, the air of bed-chambers should be 
always kept at a moderate temperature — so as to be perfectly grateful to 
the feelings of the sick- not so as l<> produce chilliness. When the febrile 
heat is high and burning, and the skin drj, the continued application of cold 
water to the hands, wrists, and tenples, and sometimes also to the feet and 
ancles, proves exceedingly pleasant, and is, at the same time, highly effica- 
cious in moderating the excess of arterial action. The water may br applied 
either by means of wet cloths, frequently renewed, or by repeated arT«. 



PRACTICE OF PHYSIC. 161 

134. A second sedative power, which may be em- 
ployed in fevers, is that of certain medicines, known, in 
the writings on the Materia Medica, under the title of 

REFRIGERANTS. 

The chief of these are acids of all kinds, when suffi- 
ciently diluted; and they are, in several respects, reme- 
dies adapted to continued fevers. Those especially in 
use are, the Vitriolic and Vegetable; and, on many ac- 
counts, we prefer the latter. 

135. Another set of refrigerants are, the Neutral 
Salts, formed of the vitriolic, nitrous, or vegetable acids; 
with alkalines, either fixed or volatile. All these neutrals, 
while they are dissolving in water, generate cold; but as 
that cold ceases soon after the solution is finished, and 
as the salts are generally exhibited in a dissolved state, 
their refrigerant power in the animal body does not at 
all depend upon their power of generating cold with 
water. The neutral chiefly employed as a refrigerant, 
is Nitre; but all the others, compounded as above men- 
tioned, partake more or less of the same quality.* 

sions. In this case particularly great caution is requisite, lest some degree 
of chillness result from the operation. 

Having but little experience in the practice of either general affusion, or 
sponging the body and extremities with cold water, in febrile diseases, we 
do not feel authorised to offer, on that subject, any remarks. From the re- 
ports, however, of practical writers of high standing, we are not permitted 
to doubt of their efficacy. 

* The addition of tartarized antimony to nitre, when not forbidden by the 
condition of the stomach, or some other particular cause, increases very 
greatly its febrifuge powers. 

Ten or twelve grains of the nitre combined with the sixth or eighth of a 
grain of the antimony — in some cases with the fourth of a grain — and admi- 
nistered every two hours, or oftener, if the stomach can bear it, is an active, 
remedy in the reduction of fever. 

Some practitioners prefer to the tartarized antimony, the addition of a 
grain or two of ipecacuanha to each dose of the nitre. 

In these cases, the salutary effect is rarely, if ever, produced, unless some 
degree of nausea be experienced from the remedy. The stomach then 
sympathizes with the vascula? system, and moderates its action. 
VOL. I. X 



162 -PRACTICE OF PHYSIC. 

136. Besides these neutrals, some metallic salts also 
have been employed as refrigerants in fevers; and par- 
ticularly the Sugar of Lead. But the refrigerant powers 
of this are not well ascertained; and its deleterious qua- 
lities are too well known to admit of its being freely 
used.* 

137. Under the third general head (128. 3.) of the 
means to be employed for moderating the violence of 
reaction, are comprehended the several means of dimi- 
nishing the tension, tone, and activity of the sanguife- 
rous system. As the activity of this system depends, in 
a great measure, upon the tone, and this again upon 
the tension of the vessels, given to them by the quan- 
tity f fluids they contain, it is evident that the diminu- 
tion of the quantity of these must diminish the activity 
of the sanguiferous system. 

138. The quantity of fluids contained in the sangui- 
ferous system, may be diminished most conveniently by 
the evacuations of blood-letting and purging. 

139. Nothing is more evident, than that blood-letting 
is one of the most powerful means of diminishing the 
activity of the whole body, especially of the sanguife- 
rous system; and it must therefore be the most effectual 
means of moderating the violence of reaction in fevers. 
Taking this as a fact, I omit inquiring into its mode of 
operation, and shall only consider in what circum- 
stances of fevers it may be most properly employed. 

140. When the violence of reaction, and its constant 
attendant, a phlogistic diathesis, are sufficiently mani- 
fest; when these constitute the principal part of the 
disease, and may be expected to continue throughout 

* Sugar of lend, exhibited in combination with opium, proves useful in 
cases of febme hemorrhagy ; but we have never known it to be administer- 
ed with advantage as a mere febrifuge. From two to five grains of the su- 
gar, in combination with half a grain of opium, may be given with safety at 
3 dose, and repeated as often as circumstances require. 



PRACTICE OF PHYSIC. 163 

the whole of it, as in the case of synocha; then blood- 
letting is the principal remedy, and may be employed ad 
far as the symptoms of the disease may seem to require, 
and the constitution of the patient will bear. It is, how- 
ever, to be attended to, that a greater evacuation than is 
necessary, may occasion a slower recovery, may render 
the person more liable to a relapse, or may bring on 
other diseases. 

141. In the case of synocha, therefore, there is little 
doubt about the propriety of blood-letting: but there 
are other species of fever, as the synochus, in which a 
violent reaction and phlogistic diathesis appear, and 
prevail during some part of the course of the disease; 
while, at the same time, these circumstances do not 
constitute the principal part of the disease, nor are to 
be expected to continue during the whole course of it, 
and it is well known, that in many cases the state of 
violent reaction is to be succeeded, sooner or later, by 
a state of debility, from the excess of which the dan- 
ger of the disease is chiefly to arise. It is, therefore, 
necessary, that, in many cases, blood-letting should be 
avoided, and even although, during the inflammatory 
state of the disease, it may be proper, it will be neces- 
sary to take care that the evacuation be not so large as 
to increase the state of debility which is t© follow. 

142. From all this it must appear, that the employ- 
ing blood-letting, in certain fevers, requires much dis- 
cernment and skill, and is to be governed by the con- 
sideration of the following circumstances; 

1. The nature of the prevailing epidemic. 

2. The nature of the remote cause. 

3. The season and climate in which the disease oc- 
curs. 

4. The degree of phlogistic diathesis present. 
o. The period of the disease, 



164 PRACTICE OF PHYSIC. 

6. The age, vigour, and plethoric state of the patient. 

7. The patient's former diseases and habits of blood- 
letting. 

8. The appearance of the blood drawn out. 

9. The effects of the blood-letting that may have 
been already practised.* 

* There are in medicine but few points that are attended with greater 
difficulty, than to give abstract rules for the practice of blood-letting. In 
relation to this remedy, every case of disease resembles precisely a case in 
equity — it must be governed by its own circumstances; and, it is needless 
to add, that there are very few,cases exactly alike. 

Of the nine precautions which our author has here given, on the subject 
of blood-letting, there are four, which, for correctness and weight, cannot 
rank with his precepts in general. They are 
1st. "The nature of the remote cause." 

We are at a loss to perceive what material influence this can have in re- 
lation to blood-letting. Our practice is to be directed, not by the remote, 
but by the proximate causes of disease. Th's the professor has himself, in 
another place, expressly acknowledged. "The cure of diseases," says he, 
"is chiefly, and almost unavoidably, founded in the knowledge of their 
proximate causes." Whence is it, then, that he here attaches so much im- 
portance to the remote cause ? It is certainly to the proximate cause or 
•nture of the disease, as far as it can be discovered, that all our remedies 
ought to be suited. 
2d. "The season and climate in which the disease occurs." 
These are considerations, which, with the experienced physician, have 
but little weight when he is making up his mind on the subject of blood-let- 
ting. If other circumstances call for it, he will bleed in August as readily 
as in January, and beneath the equator with as little hesitation as within the 
polar circles. He will be governed in his practice by neither circumstance, 
but exclusively by the state of his patient's system. 
3d. " The period of the disease." 

This consideration has some weight ; but by no means so much as is 
usually claimed for it. As a general rule, the early stages of fever are those 
in which blood-letting is most safe and efficacious : but its utility, as a remedy, 
is not confined exclusively to these. It is oftentimes employed with great 
advantage in an advanced age. 

4th. "The age, vigour, and plethoric state of the patient." 
Whatever weight these considerations may have in determining the quan- 
tity of blood that ought to be drawn, they can have exceedingly little in set- 
tling the question as to the propriety of the operation. 

The diseases of childhood and old age call for blood-letting no less impe- 
riously than those of manhood; and it is well known, that the lean and deli- 
cate are oftentimes subject to the most inflammatory complaints. 
Regardless, therefore, of age and habit, we say again, let the physician at- 



PRACTICE OF PHYSIC. 165 

143. When, after the consideration of these circum- 
stances, blood-letting is determined to be necessary, it 
should be observed, that it is more effectual, according 
as the blood is more suddenly drawn off, and as the 
body is at the same time more free from all irritation, 
and consequently when in a posture in which the few- 
est muscles are in action. 

144. Another evacuation whereby the quantity k of 
fluids contained in the body can be considerably dimi- 
nished, is that of purging. 

145. If we consider the quantity of fluids constantly 
present in the cavity of the intestines, and the quantity 
which can be drawn from the innumerable excretories 
that open into this cavity, it will be obvious that a very 
great evacuation can be made by purging; and, if this 
be done by a stimulus applied to the intestines, without 
being at the same time communicated to the rest of 
the body, it may, by emptying both the cavity of the 
intestines, and the arteries which furnish the excretions 
poured into it, induce a considerable relaxation in the 
whole system; and therefore, purging seems to be a re- 
medy suited to moderate the violence of reaction in fe- 
vers. 

146 But it is to be observed, that as the fluid drawn 
from the excretories opening into the intestines, is not 
all drawn immediately from the arteries, as a part of it 
is drawn from the mucous follicles only; and what is 
even more immediately drawn from the arteries, is 
drawn off slowly, so the evacuation will not, in propor- 
tion to its quantity, occasion such a sudden depletion of 
the red vessels, as blood-letting does; and therefore can- 
not operate so powerfully in taking off the phlogistic 
diathesis of the system* 

tend with strictness to the state of his patient's system, and he will rarely 
err as to the practice of blood-letting'. 

* In bilious fevers, and all others where there is an excess of action in the 



166 PRACTICE OF PHYSIC. 

147. At the same time, as this evacuation may induce 
a considerable degree of debility; so, in those cases, in 
which a dangerous state of debility is likely to occur, 
purging is to be employed with a great deal of caution; 
and more especially as the due measure of the evacua- 
tion is more difficult to be applied than in the case of 
blood-letting.* 

148. As we shall presently have occasion to observe, 
that it is of great importance, in the cure of fevers, to 
restore the determination of the blood to the vessels on 
the surface of the body; so purging, as in some mea- 
sure taking off that determination, seems to be an eva- 
cuation not well adapted to the cure of fevers. 

149. If, notwithstanding these doubts, (146. 147. and 
148.) it shall be asserted, that purging, even from the 
exhibition of purgatives, has often been useful in fevers; 
I would beg leave to maintain, that this has not hap- 
pened from a large evacuation; and therefore, not by 
moderating the violence of reaction, excepting in the 
case of a more purely inflammatory fever, or of exan- 
themata of an inflammatory nature. In other cases of 

viscera of the abdomen, copious purging is an indispensable remedy. Be- 
sides removing the irritation of the faeces, it acts like topical depletion, by 
cups or leeches, on an inflamed part 

* The caution inculcated in this section is very important. In cases of 
great debility, plentiful purging is a dangerous process, unless where the 
debility arises, as it sometimes does, from a morbid irritation in the stomach 
or bowels. In such a case the removal of the irritation augments the strength. 

Towards the close of fevers, when the strength of patients is greatly ex- 
hausted, severe purging has been known to be productive of death from 
syncope. This, however, has been more particularly the case, when, in- 
stead of remaining in a recumbent posture, and making use of abed-pan, 
the sick have risen up, and made improper exertions in going from the bed 
to the close-stool In the Influenza of 1815. a patient under our own care, 
who had passed in safety through the disease, lost his life in this way. He 
took a saline purgative, but was directed not to leave his bed He neglected 
the advice, made an attempt to go to the close-stool, fainted, and never re 
covered. In cases of great debility, such a practice should be rigidly pro- 
hibited. 



PRACTICE OF PHYSIC. 167 

fever, I have seen a large evacuation by purging, of 
mischievous consequence; and if upon occasion, a more 
moderate evacuation has appeared to be useful, it is ap- 
prehended to have been only by taking off the irrita- 
tion of retained faeces, or by evacuating corrupted hu- 
mours, which happened to be present in the intestines; 
for both of which purposes, frequent laxatives may be 
properly employed. 

150. Another set of means (127. 2.) for moderating 
the violence of reaction in fevers, are those suited to 
take off the spasm of the extreme vessels, which we be- 
lieve to be the irritation that chiefly supports the reac- 
tion.* 

Though I have put here this indication of taking off 
the spasm of the extreme vessels, as subordinate to the 
general indication of moderating the violence of reac- 
tion; it is, however, to be observed here, that as fever 
universally consists in an increased action of the heart, 
either in frequency or in force, which in either case is 
supported by a spasm of the extreme vessels, so the in- 
dication for removing this is a very general one, and ap- 
plicable in almost every circumstance of fever, or at 

* Cutaneous secretion, or, as it is more commonly termed, perspiration, is 
a natural function ; and, as it is checked or suspended in most cases of fever, 
ought to be restored ; which is, perhaps, all that, in reality, Dr. Cullen 
meant by " taking off the spasm of the extreme vessels." So far, therefore, 
his indication is correct and natural. Nor have we any material fault to find 
with his means of effecting it ; but his reasoning as to their modus operandi is 
altogether mechanical and unsatisfactory. 

The excitement of perspiration is a vital sympathetic process ; not a gross 
mechanical one, depending on a mere distention of the blood-vessels. The 
articles exhibited for the purpose act on the stomach, and produce an asso- 
ciated action of the cutaneous capillaries. By a plentiful draught of some 
warm liquid, when the body is cool, or of cold water alone, when it is heated, 
a perspiration is oftentimes produced too instantaneously, to be explicable 
otherwise than on principles of sympathy. 

Balm and sage, mint and chamomile teas, taken in plentiful draughts, fre- 
quently repeated, and of a temperature as high as may be agreeable to the 
sick, are exceedingly useful in promoting a perspiration; the more so, per- 
haps, on account of the slight aroma which they contain. 



168 PRACTICE OF PHYSIC. 

least, with a few exceptions, to be taken notice of here- 
after. 

151. For taking off the spasm of the extreme vessels, 
the means to be employed are either internal or exter- 
nal. 

152. The internal means (151.) are, 

1. Those which determine the force of the circula- 
tion to the extreme vessels on the surface of the body, 
and, by restoring the tone and activity of these vessels, 
may overcome the spasm on their extremities. 

2. Those medicines which have the power of taking 
off spasm in any part of the system, and which are 
known under the title of antispasmodics. 

153. Those remedies which are fit to determine to 
the surface of the body, are, 

1. Diluents. 

2. Neutral Salts. 

3. Sudorifics. 

4. Emetics. 

154. Water enters, in a large proportion, into the 
composition of all the animal fluids, and a large quantity 
of it is always diffused through the whole of the com- 
mon mass. Indeed, in a sound state, the fluidity of the 
whole mass depends upon the quantity of water present 
in it. Water, therefore, is the proper diluent of our 
mass of blood; and other fluids are diluent only in 
proportion to the quantity of water they contain. 

155. Water may be said to be the vehicle of the seve- 
ral matters which ought to be excerned; and in a healthy 
state the fulness of the extreme vessels, and the quantity 
of excretions, are nearly in proportion to the quantity of 
water present in the body. In fever, however, although 
the excretions are in some measure interrupted, they 
continue in such quantity as to exhale the more fluid 
parts of the blood ; and while a portion of them is at the 



PRACTICE OF PHYSIC. J QQ 

same time necessarily retained in the larger vessels, the 
smaller and the extreme vessels, both from he deficiency 
of fluid, and their own contracted state, are less filled, 
and therefore allowed to remain in that condition. 

156. To remedy this contracted state, nothing is more 
necessary than a large supply of water or watery fluids, 
taken in by drinking or otherwise; for as any superflu- 
ous quantity of water is forced off by the several excre- 
tories, such a force applied, may be* a means of dilating 
the extreme vessels, and of overcoming the spasm af- 
fecting their extremities. 

157. Accordingly the throwing in of a large quantity 
of watery fluids has been, at all times, a remed) much 
employed in fevers; and in no instance more remarka- 
bly than by the Spanish and Italian physicians, in the 
use of what they call the Diceta aquea. 

158. This practice consists in taking away every other 
kind of aliment and drink, and in giving in divided por- 
tions every day, for several days together, six or eight 
pounds of plain water, generally cold, but sometimes 
warm. All this, however, is to be done only after the dis- 
ease has continued for some time, and, at least, for a week. 

159. A second means (153. 2.) of determining to the 
surface of the body, is by the use of neutral salts. These, 
in a certain dose taken into the stomach, produce, soon 
after, a sense of heat upon the surface of the body; and, 
if the body be covered close and kept warm, a sweat is 
readily brought out. The same medicines, taken during 
the cold stage of a fever, very often put an end to the 
cold stage, and bring on the hot ; and they are also re- 
markable for stopping the vomiting which so freqis.'itly 
attends the cold stage of fevers. All this shows, that 
neutral salts have a power of determining the blood to 
the surface of the body, and may therefore be of use 
in taking off the spasm which in fevers subsists there. 

vol. i. y 



170 PRACTICE OF PHYSIC. 

160. The neutral most commonly employed in fevers, 
is that formed of an alkali with the native acid of vege- 
tables; but all th other neutrals have more or less of 
the same virtue; and perhaps some of them particularly 
the ammoniacal salts, possess it in a stronger degree.* 

161. As cold water taken into the stomach, often 
shows the same diaphoretic effects with the neutral 
salts, it is probable that the effect of the latter depends 
upon their refrigerent powers mentioned above, (134.) 
What is the effect of the neutral salts, given when they 
are forming and in a state of effervescence? It is pro- 
bable that this circumstance may increase the refrige- 
rent power of these salts, and may introduce into the 
body a quantity of fixed air; but for these purposes it 
would seem proper to contrive that the whole of the 
effervescence should take place in the stomach. 

162. A third means (153. 3.) of determining to the 
sulfa ce of the body, and taking off the spasm subsist- 
ing there, is by the use of sudorific medicines, and of 
sweating. 

* Our author here alludes, most pmbably, to the neutral mixture formed by 
the vegetable alkali saturated with lime juice, and to the spiritus Mindereri. 
The former of these may be made to consist of the following proportions of 
the ingredients : 

R. Alkali. Vegetabil 9'i 
Succ Limon 5ss. 
Aquae Font. 3iss. 
M f haust. 

This, if swallowed while in the act of effervescence, and repeated at pro- 
per intervals — say every hour or ofiener if necessary — is more remarkable 
for its anti-emetic than its sudorific effects. 

The Spts Minderer. consists of a saturated solution of muriate of ammonia 
in distilled vinegar. When administered every two hours, in half-ounce 
doses diluted in water, it is deemed efficacious in th.- excitement of a per- 
spiration. Compared, however, with certain others, we believe it to be a 
weak and inefficient remedy It is therefore that we have rarely employed 
it in practice. If, during the use of it, the body be kept cool, it has the re- 
putation of proving an active diuretic. To produce any medicinal effect, it 
must be taken m such doses as to be felt in the stomach : for, like other in- 
ternal remedies, it operates only through, the sympathies of that organ. 



PRACTICE OF PHYSIC. 171 

163. The propriety of this remedy has been much 
disputed; and specious arguments may be adduced 
both for and against .this practice.* > 

In favour of the practice it may be said, 

1. That, in healthy persons, in every case of increas- 
ed action of the heart and arteries, a sweating takes 
place and is seemingly the means of preventing the bad 
effects of such increased action. 

2. That, in fevers, their most usual solution and ter- 
mination is by spontaneous sweating. 

3. That, even when excited by art, it has been found 
manifestly useful, at certain periods, and in certain 
species of fever. 

164. Upon the other hand, it may be urged against 
the practice of s wealing, 

1. That as in fevers a spontaneous sweating does not 
immediately come on, so there must be in these some 
circumstances different from those in a state of health, 
and which may therefore render it doubtful whether 
the sweating can be safely excited by art. 

2. That in many cases, the practice has been attend- 
ed with bad consequences. The means commonly em- 
ployed have a tendency to produce an inflammatory 
diathesis; which, if not taken off by the sweat following 
their use, must be increased with much danger. Thus, 
sweating employed to prevent the accessions of inter- 
mitting fevers, has often changed thein into a conti- 
nued form, which is always dangerous. 

3. The utility of the practice is further doubtful, be- 

* A forced sweat but rarely does good, and is oftentimes productive of 
much exhaustion and distress. To be really useful it must flow somewhat 
spontaneously; at least with facility. If the practitioner, therefore, find 
much d'fficulty in exciting a sweat, he had better, for the time, relinquish 
the attempt. His persevering efforts will exhaust his patient rather than 
the disease. 



172 PRACTICE OF PHYSIC. 

cause sweating, when it happens, does not always give 
a final determination; as must be manifest in the case 
of intermittens, as well as in many continued fevers, 
which are sometimes in the beginning attended with 
sweatings that do not prove final; and. on the contrary, 
whether spontaneous or excited by art, seem often to 
aggravate the disease 

165. From these considerations, it is extremely 
doubtful if the practice of sweating can be admitted 
very generally but at the same time, it is also doubtful, 
if the failure of the practice, or the mischiefs said to 
have arisen from it, have not been owing to the impro- 
per conduct of the practitioner. With respect to this 
last, it is almost agreed among physicians, 

1. That sweating has been generally hurtful, when 
excited by stimulant, heating, and inflammatory medi- 
cines. 

2. That it has been hurtful, when excited by much 
external heat, and continued with a great increase of 
the heat of the body. 

3. That it is always hurtful, when it does not soon 
relieve, but rather increases, the frequency and hard- 
ness of the pulse, the anxiety and difficulty of breath- 
ing, the headach, and delirium. 

4. That it is always hurtful, if it be urged when the 
sweat is not fluid, and when it is partial, and on the 
superior parts of the body only. 

166. In these cases, it is probable, that either an in- 
flammatory diathesis is produced, which increases the 
spasm on the extreme vessels; or that, from other causes, 
the spasm is too much fixed to yield easily to the in- 
creased action of the heart and arteries; and, upon 
either supposition, it must be obvious, that urging the 
sweat, as ready to produce a hurtful determination to 



PRACTICE OF PHYSIC. 173 

uome of the internal parts, may be attended with very 
great danger. 

167. Though the doubts started (164.) are to be at- 
tended to; and although the practices (165.) having been 
found hurtful, are therefore to be rejected; it still re- 
mains true, 

1. That sweating has certainly been often useful in 
preventing the accession of fevers, when the times of 
this have been certainly foreseen, and a proper conduct 
employed. 

2. That, even after fevers have in some measure 
come on, sweating, when properly employed, either at 
the very beginning of the disease, or during its ap- 
proach and gradual formation, has often prevented their 
further progress. 

.3. That, even after pyrexias have continued for some 
time, sweating has been successfully employed in cur- 
ing them, as particularly in the case of rheumatism. 

4. That certain fevers, produced by a very powerful 
sedative contagion, have been generally treated, so far 
as we yet know, most successfully by sweating. 

168. These instances (167.) are in favour of sweat- 
ing, but give no general rule; and it must be left to fur- 
ther experience to determine how far any general rule 
can be established in this matter. In the mean time, if 
the practice of sweating is to be attempted, we can vem 
tiSre to lay down the following rules for the conduct of it. 

1. That it should be excited without the use of sti- 
mulant inflammatory medicines. 

2. That it should be excited with as little external 
beat, and with as little increase of the heat of the body, 
as possible. 

3. That when excited, it should be continued for a 
due length of time, not less than twelve hours; and 
sometimes for twenty-four or forty-eight hours; always. 



174 PRACTICE OF PHYSIC. 

however, providing that it proceeds without the circum- 
stances mentioned, (165. 3. 4.)* 

4. That for some part of the time, and as long as Hie 
person can easily bear, it should be carried on without 
admitting of sleep. 

5. That it should be rendered universal over the 
whole body; and, therefore, particularly, that care be 
taken to bring the sweating to the lower extremities. 

6. That the practice should be rendered safer by 
moderate purging, excited at the same time. 

7. That it should not be suddenly checked by cold 
any how applied to the body. 

169. When attention is to be giren to these rules, the 
sweating may be excited, 1. By warm bathing, or a 
fomentation of the lower extremities. 2 By frequent 
draughts of tepid liquors, chiefly water, rendered more 
grateful by the addition of a light aromatic, or more 
powerful by that of a small quantity of wine. 3. By giv- 
ing some doses of neutral salts. 4. Most effectually, and 
perhaps most safely, by a large dose of an opiate joined 
with a portion of neutral salts, and of an emetic. 

In what cases may cold water, thrown into the sto- 
mach in large quantities, be employed to excite sweat- 
ing? See Celsus, Lib. III. Chap. vii. — ix. 

170. The fourth means (153. I.) of determining to 
the surface of the body, and thereby taking off the spasm 
affecting the extreme vessels, is by the use of emetics. 

171. Emetics, and particularly antimonial emetics, 
have been employed in the cure of fevers ever since the 
introduction of chemical medicines: but for a long 
time, they were employed by chemists and chemical 



* To continue a sweat for " forty-eight hours," permitting the patient to 
sleep but very little during that period, as must necessarily be the case, 
I would be an unreasonable, harsh, and injurious practice. Such a measure 
will not, we believe, find, at present, a single advocate. 



PRACTICE OF PHYSIC. J 75 

practitioners only: and although of late the use of them 
has become very general, their efficacy is still disputed, 
and their manner of operating is not commonly explained. 
172. Vomiting is, in many respects, useful in fevers; 
as it evacuates the contents of the stomach; as itemulges 
the biliary and pancreatic ducts: as it evacuates the 
contents of the duodenum, and perhaps, also, of a larger 
portion of the intestines; as it agitates the whole of the 
abdominal viscera, expedes the circulation in them, 
and promotes their several secretions; and lastly, as 
agitating also the viscera of the thorax, it has like effects 
there. All these several effects are, in many cases and 
circumstances of fever, procured with advantage; but 
do not properly fall under our view here, where we are 
to consider only the effect of vomiting in determining to 
the surface of the body.* 

* Our author's observations on emetics are pertinent and proper. The 
effects of these remedies, in procuring a solution of fever, is oftentimes ob- 
vious. 

We do not believe, however, with the professor, that their action on the 
stomach is confined chiefly to its " muscular fibres." It seems probable, 
that they act more particularly on its nerves. It is certain, at least, that their 
operation on that organ does not consist in their mere evacuation of its 
contents ; but, that by severely stimulating it, they act on the skin and other 
parts of the system, through the medium of its sympa-thies. The extent 
and suddenness oi their effects admit of no explanation on any other prin- 
ciple. 

When administered only in nauseating closes, they produce their general 
affects in the same way. Our author's remarks on this mode of exhibiting 
them are judicious and worthy of attention. So are his remarks on the kinds 
of these remedies that may be most advantageously employed. 

In the United States, Dover's and James' powders are not much used. 
They do not operate with so much certainty as tartar emetic or ipecacuanha, 
under proper management. 

To produce a nausea, the former of these may be administered in doses 
varying from the sixteenth to the fourth of a grain, according to the age, 
and state of the stomach, of the patient; and repeated every hour 

Of the former, from half a grain to two grains may be exhibited at the 
same intervals ; and, when combined with a little opium and prepared chalk, 
we have not found its emetic quality particularly troublesome. 

If the object be to produce the nauseating effect of tartar emetic, it may 
be usefully exhibited under the following formula. 



176 PRACTICE OF PHYSIC 

173. This effect we do not impute to the exercise of 
vomiting in agitating the whole frame; but to the par- 
ticular operation of emetics upon the muscular fibres 
of the stomach, whereby they excite the action of the 
extreme arteries on the surface of the body, so as 
thereby effectually to determine the blood into these 
vessels, remove the atony, and take off the spasm affect- 
ing them. 

1 74. That such is the power of emetics, will appear 
from the several considerations mentioned above (44.); 
and therefore, that they are remedies well suited to the 
cure of fevers. 

175. Emetics, for that purpose, are administered in 
two different ways: that is, either in such doses as may 
excite full and repeated vomitings; or in such doses as 
may excite sickness and nausea only, with little or no 
vomiting at all. 

1 76. Full vomiting is best suited to the several pur- 
poses mentioned, (112.) and is well suited to determine 
to the surface of the body, so as thereby to obviate the 
atony and spasm which lay the foundation of fever. 
Thus vomiting, excited a little before the expected ac- 
cession of the paroxysm of an intermittent, has been 
found to prevent the paroxysm altogether. And it has 
been observed also, that when contagion has been ap- 
plied to a person, and first discovers its operation, a vo- 
mit given will prevent the fever, which was otherwise 
to have been expected. See Lind on Fevers and Infec- 
tion. 

R Antimonii Tartarisati gr. ij. 
Aquae Cinnamom. simpl. §ij. 
Aquae font. § vj. 
M. f. Julep. 
Of this, one or two table spoonfuls may be given to an adult every lioui 
or oftener, according to circumstances. To children the dose must be less 
in proportion to their age. 



PRACTICE OF PHYSIC. 177 

177. These are advantages to be obtained by excit- 
ing vomiting at the first approach of fevers, or of the 
paroxysms of fevers; and after fevers are formed, vo- 
miting may also be employed to take off, perhaps en- 
tirely, the atony and spasm, or at least to moderate 
these, so that the fever may proceed more gently and 
safely. 

178. It is seldom, however, that vomiting is found to 
produce a final solution of fevers; and after they are 
once formed, it is commonly necessary to repeat the 
vomiting several times; but this is attended with incon- 
venience, and sometimes with disadvantage. The ope- 
ration of full vomiting commonly soon ceases, and the 
exercise of vomiting is often a debilitating power; and 
therefore, when the vomiting does not remove the atony 
and spasm entirely, it may give occasion to their recur- 
ring with greater force. 

179. For these reasons, after fevers are fully formed, 
physicians have thought proper to employ emetics in 
nauseating doses only. These are capable of exciting 
the action of the extreme vessels, and their operation 
is more permanent. At the same time, they often show 
their power by exciting some degree of sweat, and their 
operation is rendered more safe, by their commonly 
producing some evacuation by stool. 

180. Such are the advantages to be procured by nau- 
seating doses of emetics; and it only remains to mention, 
what are the medicines most fit to be employed in that 
manner, what are the most proper times for exhibiting, 
and what is the best manner of administering them. 

181. The emetics at present chiefly in use, are Ipe- 
cacuanha and Antimony. 

The former may be employed for every purpose of 
emetics, particularly those mentioned (172). It 
likewise be employed, either iu larger or smaller doses, 

vol. 1. z 



178 PRACTICE OF PHYSIC. 

for determining to the surface of the body; but, even in 
very small doses, it so readily excites vomiting, as to be 
with difficulty employed for the purpose of nauseating 
only; and however employed, there is reason to believe 
that its effects are less permanent, and less powerfully 
communicated from the stomach to the rest of the sys- 
tem than those of Antimony. 

182. This, therefore, is generally preferred; and its 
preparations, seemingly various, may all be referred to 
two heads; the one comprehending those in which the 
reguline part is in a condition to be acted upon by the 
aciJs; and therefore, on meeting with the acids in the 
stomach, becomes active; and the other comprehending 
those preparations in which the reguline part is already 
joined with an acid, rendering it active. 

183. Of each kind there are great numbers, but not 
differing essentially from one another. It will be enough 
for us to compare the Calx Antimonii Nitrata of the 
Edinburgh Dispensatory with the Emetic Tartar of the 
same. The former, as I judge, is nearly the same with 
what is called James's powder. Which of these is best 
suited to the cure of fevers, as above explained, seems 
doubtful; but it appears to me. that, although the for- 
mer may have some advantages from its slower opera- 
tion, and may thereby seem to be more certainly sudo- 
rific and purgative, yet the uncertainty of its dose ren- 

t ders it inconvenient, has often given occasion to the 
timid to be disappointed, and the bold to do mischief. 
On the other hand, the dose of the Emetic Tartar can 
be exactly ascertained; and I think it may be exhibited 
in such a manner as to produce all the advantages of 
the other. 

1 84. Whichsoever of these preparations be employed, 
I judge tiic most proper time for exhibiting them, to be 
the time of accession, or a little before, when that can 



PRACTICE OF PHYSIC. 179 

be certainly known. In continued fevers, the exacerba- 
tions are not always very observable; but there is rea- 
son to think, that one commonly happens about noon, or 
soon after it, and another in the evening; and that these, 
therefore, are the most proper times for exhibiting eme- 
tics. 

185. With respect to the manner of administration, 
that of the Calx Nitrata is simple, as the whole of what 
is judged a proper dose is given at once, and no more 
can properly be given till the time of the next acces- 
sion. 

The administration of the Emetic Tartar is different. 
It is to be given in small doses, not sufficient to excite 
vomiting; and these doses, after short intervals, are to 
be repeated for several times, till sickness, nausea, and 
some, but not much, vomiting, come on. The differ- 
ence of this administration must depend upon the dose, 
and the length of the intervals at which it is given. If 
it be intended that the medicine should certainly ope- 
rate by stool, the doses are made small, and the inter- 
vals long. On the contrary, when vomiting is proper, 
or when much purging ought to be avoided, and there- 
fore some vomiting must be admitted, the doses are 
made larger, and the intervals shorter. 

186. With respect to both kinds of preparations, the 
repetition is to be made, at the times of accession, but 
not very often: for if the first exhibitions, duly ma- 
naged, have little effect, it is seldom that the after exhi- 
bitions have much, and it sometimes happens that the 
repeated vomitings, and especially repeated purges, do 
harm by weakening the patient. 

187. The other set of internal medicines (152. 2.) 
which I suppose may be useful in taking off the spasm 
of the extreme vessels, are those named antispasmodic. 

How many of these may be properly employed, I am 



180 PRACTICE OF PHYSIC. 

uncertain; and their mode of operation is involved in 
great obscurity. It is certain, however, that opium, 
camphor, musk, and perhaps some others, have been 
employed in fevers with advantage; but the circum- 
stances in which they are especially proper and safe, I 
find difficult to ascertain; and therefore cannot venture 
here to lay down any general doctrine concerning them. 

188. The external means (151.) suited to take off the 
spasm of the extreme vessels, are blistering and warm 

BATHING. 

189. What are the effects of blistering, so frequently 
employed in fevers, is not yet agreed upon among phy- 
sicians; and many different opinions have been main- 
tained on this subject, drawn not only from reasoning, 
but also from presumed experience. I must not, how- 
ever, enter into controversy; but shall deliver my own 
opinion in a few words. 

190. I am persuaded, that the small quantity of can- 
tharides absorbed from a blistering plaster, is not suffi- 
cient to change the consistence of the mass of blood; 
and therefore, that such a quantity can neither do good, 
by resolving phlogistic lentor, if it exists; nor do harm, 
by increasing the dissolution of the blood arising from 
a putrid tendency in it. I therefore neglect entirely the 
effects of cantharides upon the fluids. 

191. The inflammation produced by the application 
of cantharides to the skin, affords a certain proof of 
their stimulant power; but in many persons, the effect 
of that stimulus is not considerable; in many it is not 
communicated to the whole system; and even when the 
effect does take place in the whole system, it seems to 
be taken off entirely, by the effusion and evacuation of 
serum from the blistered part. I conclude, therefore, 
that neither much good is to be expected, nor much 
harm to be apprehended, from the stimulant power of 



PRACTICE OF PHYSIC. Jgl 

blistering; and the certainty of this conclusion is esta- 
blished, by the great benefit arising from the proper 
practice of blistering in inflammatory diseases. 

192. Much has been imputed to the evacuation oc- 
casioned by blistering; but it is never so considerable 
as to affect the whole system; and therefore can neither, 
by sudden depletion, relax the sanguiferous vessels, nor, 
by any revulsion, affect the general distribution of the 
fluids. 

1 93. The evacuation, however, is so considerable as 
to affect the neighbouring vessels; and the manifest uti- 
lity of blistering near the part affected, in inflammatory 
diseases, leads me to believe, that blistering, by deriv- 
ing to the skin, and producing an effusion there, relaxes 
the spasm of the deeper seated vessels. I apprehend it 
to be in this manner, that the tumour of a joint, from 
an effusion into the cellular texture under the skin, takes 
off the rheumatic pain affecting that joint. 

1 94. Analogous to this, it may be held, that the good 
effects of blistering in continued fevers, arise from its 
relaxing the spasm of the extreme vessels, by a com- 
munication of the blistered part with the rest of the 
skin ; and this is illustrated by the effect of blistering in 
colic and dysentery.* 

195. It appears to me, that blistering may be employ- 
ed at any period of continued fevers; but that it will be 

* The mere quantity of the serous evacuation produced by blisters, can 
have no influence in their general effects. These, like other remedies, ope- 
rate entirely through the medium of sympathy, resulting from a peculiar 
local impression. They specifically stimulate the skin, on the spot to which 
they are applied, and from that, as a point of beginning, forming a new 
chain of associated actions, tend to dissolve the morbid one already exist- 
ing. It is probable that blisters affect first, by what writers denominate 
continuous sympathy, the whole, or a considerable portion of the skin ; 
while that organ, by a very extensive and powerful range of sympathies, 
which it is known to possess, more especially with the stomach, intestines, 
and lungs, communicates somewhat of its own condition to the whole system. 



182 PRACTICE OF PHYSIC. 

of most advantage in the advanced state of such fevers, 
when the reaction being weaker, all ambiguity from the 
stimulant- power of blistering is removed, and when it 
may best concur with other circumstances tending to a 
final solution of the spasm.* 

196. From the view of this matter given in (193. and 
194.) it will appear, that the part of the body to which 
blisters ought to be applied, is indifferent, excepting up- 
on the suspicion of topical affection, when the blister- 
ing ought to be made as near as possible to the part 
affected. f 

197. Whether sinapisms and other rubefacientia, 
act in a manner analogous to what we have supposed of 
blistering, may be doubtful; but their effects in rheuma- 
tism, and other inflammatory diseases, render it probable. 

198. The other external means of taking off the spasm 
of the extreme vessels, is Warm Bathing. This was 
frequently, and in various circumstances, employed by 
the ancients; but till very lately has been neglected by 
modern physicians. As the heat of the bath stimulates 
the extreme vessels, and, with the concurrence of mois- 
ture, also relaxes them, it seems to be a safe stimulus, 
and well suited to take off the spasm affecting them. 

* Blisters cannot be applied with advantage nor even with safety " at any 
period of continued fevers." If they be applied during an early period, 
when the morbid action is highly inflammatory, they cannot fad to do mis- 
chief. They simply add the amount of their own stimulation to that under 
which the system is already labouring ; and, by that means, augment the 
force of febrile action. In cases of inflammatory fever, the lancet should 
have nearly completed its duty, before blisters are called to theirs. 

■j- The sentiment contained in this paragraph is not correct. In cases 
where there is no apparent local affection, there exists, notwithstanding, a 
clear choice, as to the parts of the body on which blisters should be applied. 
The skin of the upper and lower extremity, especially of the wrists and an- 
cles, appears to sympathize more strongly with the whole system than that 
of any other pan of the body. As a general rule, therefore, on these situa- 
tions, in continued fevers, let blisters be applied. We feel also persuaded 
that blisters applied along the spine, act with peculiar energy on the system 
in general. 



PRACTICE OF PHYSIC. ]83 

199. It may be applied to the whole body by immer- 
sion; but this is, in man> respects, inconvenient; and 
whether some of the inconveniences of immersion might 
not be avoided by a vapour-bath, I have not learned 
from experience. I know, however, from much experi- 
ence, that most of the purposes of warm bathing can 
be obtained by a fomentation of the legs and feet, if 
properly administered, and continued for a due length 
of time, which ought not to be less than an hour* 

200. The marks of the good effects of such a fomen- 
tation, are, the patient's bearing it easily, its relieving 
delirium, and inducing sleep. 

201. Having now considered the several means of 
satisfying the first general indication in the cure of 
fevers, I proceed to the second, ( 126.; which is, To re- 
move the cause or obviate the effects of debilitij. 

202. Most of the sedative powers inducing debility, 
cease to act soon after they have been first applied; and, 
therefore, the removing them is not an object of our 
present indication. There is only one which may be 
supposed to continue to act for a long time; and that is, 
the contagion applied: but we know nothing of the na- 
ture of contagion that can lead us to any measures for 
removing or correcting it. We know only its effects as 
a sedative power inducing debility, or as a ferment in- 
ducing a tendency to putrefaction in the fluids. The 
obviating the latter will be considered under our third 
general indication, and the former alone is to be con- 
sidered here.f 



* A vapour bath, formed simply by wetting hot bricks with vinegar or 
water, and placing them under the bed-clothes, has a powerful influence in 
exciting a perspiration ; which is all that our author can mean, by a removal 
of the spasm from the cutaneous vessels. 

-j- For a knowledge of our sentiments on sedatives and putridity, the read- 
er is referred to what we have said on former occasions. We shall, at pre- 
sent, only add, that what is usually considered as a putrescent state of the 



184 PRACTICE OF PHYSIC. 

203. The debility induced in fevers by contagion, or 
other causes, appears especially in the weaker energy 
of the brain; but in what this consists, or how it may 
be directly restored, we do not well know. As nature, 
however, does, seemingly for this purpose, excite the ac- 
tion of the heart and arteries, we ascribe the continuance 
of debility to the weaker reaction of the sanguiferous 
system; so that the means to be employed for obviating 
debility, are immediately directed to support and in- 
crease the action of the heart and arteries; and the 
remedies used are tonics or stimulants. 

204. In contagious diseases, both from the effects 
which appear, and from dissections, it is known that 
the tone of the heart and arteries is considerably di- 
minished; and that tonic remedies, therefore, are pro- 
perly indicated. 

These are to be considered as of two kinds: the 
first being the power of cold, the second that of tonic 
medicines. 

205. The power of cold, as a tonic, I have mention- 
ed above; (90.) and it is employed, in fevers, in two 



blood, preventing that fluid from coagulating when drawn from the veins, is 
nothing more than its possessing too little vitality to enable it to contract as 
it does when in a healthy condition Its escape from the small veins, form- 
ing petechia:, vibices, and maculae, far from bespeaking in it any unusual 
thinness, arises from the want of a sufficiency of the via vitx in those vessels 
to qualify them to retain it. Instead of inspissants, therefore, or any kind of 
correctives of the blood, the only proper remedies here, are tonics, or such 
articles as communicate vital strength to the solid fibre. 

The question, in this case, is not, whether the blood, when drawn from 
the veins of a patient covered with vibices, will putrefy sooner than ii does 
when taken from a person in health ? This it will certainly do, owing to its 
destitution of the necessary stock of the vital principle, which is the most 
powerful and efficient antiseptic in nature. The pathological point to be 
settled is, whether that fluid, when circulating in its proper vessels, be in- 
fected by any degree of a putrid taint? This we positively deny, and have 
already referred to the authority (Dr. Sybert's Inaugural Dissertation) on 
which, in part, our opinion is founded. 



PRACTICE OF PHYSIC. 135 

ways; either as the cold matter is thrown into the sto- 
mach, or as it is applied to the surface of the body. 

206. As it has been shown above, that the tonic 
power of cold can be communicated from any one 
par* to every other part of the system; so it will rea- 
dily be allowed, that the stomach is a part as fit for 
this communication as any other; and that cold drink, 
taken into the stomach, may, therefore, prove an use- 
ful tonic in fevers. 

207. This the experience of all ages has confirmed; 
but, at the same time, it has been frequently observed, 
that, in certain circumstances, cold drink, taken into 
the stomach, has proved very hurtful; and, therefore, 
that the use of cold drink in fevers requires some limi- 
tations. What these limitations should be, and what 
are all the circumstances which may forbid the use of 
cold drink, is difficult to determine; but it seems clear- 
ly forbidden, in all cases where a phlogistic diathesis 
prevails in the system, and more especially when there 
are topical affections of an inflammatory nature.* 

208. The other method of employing cold as a to- 
nic, is, by applying it to the surface of the body. The 
application of cold air to the surface of the body, as a 
refrigerant power fit to moderate the violence of reac- 
tion, I have spoken of above; (133.) but probably it 
may also be considered here as a tonic, and useful in. 
cases of debility. 

* In relation to cold drinks, we believe that they never prove injurious in 
febrile diseases, unless when taken at a temperature so low, or in quantities 
so copious, as to prodace a sensation of chilliness. If an effect like this re- 
sult from them, no matter whether the phlogistic or antiphlogistic diathesis 
mark the disease, their use ought to be immediately discontinued. But if, 
on the other hand, their employment be productive of pleasurable sensa- 
tions, the continuance of them will be not only safe but advantageous In 
this point of view, they may be considered as a tonic in fevers of a typhous 
character, and a refrigerant in inflammatory ones. 

vol. i. A a 



186 PRACTICE OF PHYSIC. 

209. Not only cool air, but cold water also, may be 
applied to the surface of the body, as a refrigerant, and 
perhaps as a tonic. The ancients frequently applied it 
with advantage, to particular parts, as a tonic; but it 
is a discovery of modern times, that in the case of pu- 
trid fevers, attended with much debility, the body may 
be washed all over with cold water. 

210. This was first practised at Breslaw in Silesia, 
as appears from a dissertation, under the title of Epide- 
mia verna quce fVratislaviam, anno 1737, afflixit, to 
be found in the appendix to the Acta. Nat. Cwios. Vol. 
X. And from other writers we find, that the practice 
has passed into some of the neighbouring countries; al- 
though in this island, so far as I know, we have hitherto 
had no experience of it. 

211. The medicines which have been employed in 
fevers, as tonics, are various. If the Saccharum Saturni 
has been found useful, it is, probably, as a tonic, ra- 
ther than as a refrigerant; and the Ens Veneris, or 
other preparations of iron which have been employed, 
can act as tonics only. The preparations of copper, 
from their effects in epilepsy, are presumed to possess a 
tonic power; but whether their use in fevers be founded 
upon their tonic or their emetic powers may be uncertain. 
The use of arsenic and of alum, in intermittent fevers, 
seems manifestly to depend upon their tonic power. 
And, upon the whole, there may occur cases of conti- 
nued fevers, which may be cured by tonics taken from 
the fossil kingdom; but the use of these has been rare, 
as well as the effects uncertain; and physicians have 
employed more commonly the vegetable tonics.* 



* Preparations of copper and arsenic do not act as tonics in Uie cure of in- 
termitting fever. They act as irritants or morbific stimuli. They produce ;>. 
diseased impression on the stomach, stronger than that of marsh miasmata 



PRACTICE OF PHYSIC. 187 

212. A great variety of these has been employed in 
the cure of intermittent fevers; but how many of them 
may be employed in continued fevers, or in what cir- 
cumstances of these fevers, is not well ascertained; and 
I shall now only consider the question with respect to 
the most celebrated of these tonics, the Peruvian Bark. 

213. This bark has been commonly considered as a 
specific, or as a remedy of which the operation was not 
understood. But it is certainly allowable to inquire 
into this matter; and I apprehend it may be explained. 

214. To this purpose it may be remarked, that as, 
in many cases, the effects of the bark are perceived 
soon after its being taken in the stomach, and before it 
can possibly be conveyed to the mass of blood, we may 
conclude, that its effects do not arise from its operating 
on the fluids; and must, therefore, depend upon its 
operating on the nerves of the stomach, and being 
thereby communicated to the rest of the nervous system. 
This operation seems to be a tonic power, the bark 
being a remedy in many cases of debility, particularly 
in gangrene; and, as the recurrence of the paroxisms 
of intermittent fevers depends upon a recurrence of 
atony, (35. and 36.) so probably the bark,, by its tonic 
power, prevents the recurrence of these paroxysms; 
and this is greatly confirmed by observing, that many 
other tonic medicines answer the same purpose.* 

It is an impression, however, which will terminate in health, as soon as the 
cause which gives rise to it is withheld. 

If weunderst and the word tonic, it means a medicine that adds strength to 
healthy action. Such, however, is not the effect of copper or arsenic As 
far as our experience extends, these articles, instead of increasing healthy 
action, never remove intermitting fever, until they have first very materially 
disordered the stomach. Arsenic, in particular, produces a disease of that 
organ perfectly svi generis, which entirely obliterates, for the time, the irri- 
tation resulting from the cause of the malady it is intended to cure. 

* The Peruvian bark is, perhaps, the most perfect, pure, and powerful 
tonic belonging to the materia medica. It is never given, therefore, withou* 
doing mischief, in cases where the phlogistic diathesis prevails. 



188 PRACTICE OF PHYSIC. 

215. If the operation of the bark mav be thus ex- 
plained, from its possessing a tonic power, it is easy to 
perceive why it is improper when a phlogistic diathesis 
prevails; and from the same view, we can ascertain in 
what cases of continued fever it may be admitted. 
These are either after considerable remissions have 
appeared, when it may be employed to prevent the re- 
turn of exacerbations, on the same footing that it is 
used in intermittent fevers, or in the advanced state of 
fevers, when all suspicion of an inflammatory state is 
removed, and a general debility prevails in the system; 
and its being then employed is sufficiently agreeable to 
the present practice. 

216. With respect to the use of the bark, it is pro- 

We believe, with Dr Cullen, that in curing fever, its immediate effects 
are confined to the stomach. Were it to enter the lacteals, it would be as 
crnle; were it to be carried into the blood-vessels, it would be in the form 
of blood. In neither case would it be capable of producing a medicinal ef- 
fect. A medicine, in the true sense of the word, is something which the 
stomach cannot digest. This is the case with regard to the Peruvian bark. 
That oryan cannot prepare it for the purposes of nourishment. 

The bark, although it does not, like arsenic, greatly disorder the stomach, 
produces in it, notwithstanding, a degree or mode of action peculiar to it- 
self It is, in its effects, as perfect a specific, as mercury or cantharides, 
asafoetida or opium. By its operation on the stomach, it changes entirely 
the condition of that viscus, and obliterates the effect produced on it by the 
febrile cause. 

We consider it as a position almost self-evident, that those febrile diseases 
which are particularly removed by the exhibition of the bark, have their 
original seat in the stomach. It is because this local affection is in that or- 
gan, and is not of an inflammatory character, that the remedy we are consi- 
dering is calculated for its cure 

Provided the stomach will retain it, the bark should be always given in 
substance. The second best preparation is the extract ; and next to that the 
decoction The tincture is not a very efficient remedy, and has often proved 
injurious by inducing a fondness for ardent spirits. 

Bark finely pulverized may be given in doses of a drachm weight, or a 
heaped tea-spoonful, to be repeated every hour, or oftener according to cir- 
cumstances. To those who prefer it in that way, it may be given in the 
form of pills to the same amount. 



PRACTICE OF PHYSIC. 189 

per to add, that good effects are to be expected from 
it, almost only when given in substance and in large 
quantity. 

217. Another set of Medicines to be employed for 
obviating debility and its effects, are the direct stimu- 
lants, (20:3.) These, in some measure, increase the 
tone of the moving fibres; but they are different from 
the tonics, as more directly exciting and increasing the 
action of the heart and arteries. This mode of their 
operation renders the use of them ambiguous; and when 
an inflammatory diathesis is present, as so often hap- 
pens in the beginning of fevers, the effects of these sti- 
mulants may be very hurtful; but it still remains pro- 
bable, that in the advanced state of fevers, when debi- 
lity prevails, they may be useful. 

218. What are the stimulants that may be most pro- 
perly employed, I am uncertain, as the use of them in 
this age has been rare; but I am disposed to believe 
that, of all kinds, wine is the best. 

2 1 9. Wine has the advantage of being grateful to the 
palate and stomach, and of having its stimulant parts so 
much diluted, that it can be conveniently given in small 
doses; so that it may be employed with sufficient caution; 
but it is of little service, unless taken pretty largely. 

220. It may be supposed, and on good grounds, that 
wine has an operation analogous to that of opium, and 
some other narcotic medicines. It may indeed be said, 
that we can distinctly mark its stimulant power only, 
which renders its effects in the phrenitic delirium mani- 
festly hurtful, and, in the mild delirium, depending on 
d< bility, as remarkably useful. But in all this the ana- 
logy with opium is still obvious; and it is probable, that 
both wine and opium are more useful by their sedative 
and antispasmodic, than by their stimulant powers. 

221. These are the means of answering our second 



190 PRACTICE OF PHYSIC. 

general indication; (\2G. 2.) and I now proceed to the 
third, which is, to obviate or to correct the tendency of 
the fluids to putrefaction. 

222. This may be done, 

1. By avoiding any new application of putrid or pu- 
trescent matter. 

2. By evacuating the putrid or putrescent matter al- 
ready present in the body. 

3. By correcting the putrid or putrescent matter re- 
maining in the body. 

4. By supporting the tone of the vessels, and thereby 
resisting further putrefaction, or obviating its effects. 

223. The further application of putrid or putrescent 
matter may be avoided, 

1. By removing the patient from places filled with cor- 
rupted air. 

2. By correcting the air from which he cannot be re- 
moved. 

3. By preventing the accumulation of the patient's 
own effluvia, by a constant ventilation, and by a frequent 
change of bed-clothes and body linen. 

4. By the careful and speedy removal of all excre- 
mental matters from the patient's chamber. 

5. By avoiding animal food, or correcting it* 

224. The putrid or putrescent matter, already pre- 
sent in the body, may be evacuated partly by evacuating 
frequently the contents of the intestines, and more ef- 

* The physicians of Europe, especially of Great Britain, speak in high 
terms of the efficacy of nitro-muriatic acid gas in the purification of an in- 
fectious or contagious atmosphere. It may be formed by pouring the nitric 
acid on common salt. Having had no experience in the use of this article, 
we are unable to speak of it from our own knowledge. We believe that 
several physicians of the United States, who have employed it for depurat- 
ing the atmosphere of ships of war, have been pleased with its effects. 
Lime, in the way of white- washing, is much used for the same purpose. 

We are inclined to think, that nature's own method, consisting in cleanli- 
ness and free ventilation, constitutes the best purifying process. Wherever 
it may be practicable, therefore, its adoption is recommended. 



PRACTICE OF PHYSIC. \g\ 

fectually still, by supporting the excretions of perspira- 
tion and urine, by the plentiful use of diluents.* 

225. The putrid or putrescent matter remaining in 
the body, may be rendered more mild and innocent by 
the use of diluents, or may be corrected by the use of 
antiseptics. These last are of many and various kinds; 
but which of them are conveniently applicable, or more 
particularly suited to the case of fevers, is not well as- 
certained. Those most certainly applicable and useful, 
are, acescent aliments, acids of all kinds, neutral salts 
and fixed air. 

226. The progress of putrefaction maybe considera- 
bly retarded, and its effects obviated, by supporting the 
tone of the vessels; and this may be done by tonic re- 
medies; the chief of which are, Cold, and Peruvian 
Bark, both sufficiently treated of above, (250. et seq.) 

221. I have now finished the consideration of the 
three general indications to be formed in the cure of 
continued fevers, and have mentioned most of the re- 
medies which have been, upon any occasion, employed 
in this business. It was necessary, in the first place, to 
consider these indications and remedies separately, and 
to explain the operation of the latter more generally; 
but from what has been now delivered, compared with 
what was said above, concerning the difference of fe- 
vers, and the signification of their several symptoms in 
forming the prognostic, I expect it will not be difficult 
to assign the indication, and to select and combine the 
several remedies mentioned, so as to adapt them to the 
several species and circumstances of continued fevers. 

* As great prostration of strength constitutes one of the symptoms of 
what is denominated putrid fever, purges should be used cautiously, lest de- 
bility be injuriously increased. Injections and the milder purgatives ought 
to be chiefly employed. In many instances of typhus fever, no inconsider- 
able advantage is supposed to be derived from producing a constipation of 
the bowels by the use of opium. 



192 PRACTICE OF PHYSIC. 

I think it may be useful for my readers to have the whole 
of the cure of continued fevlrs brought under one 
view, as in the following table. 

IN THE CURE OF CONTINUED FEVERS, 
THE INDICATIONS AUE, 

I. To moderate the violence of reaction. 
Which may be done by, 

1. Diminishing the action of the heart and arteries, by 
A. Avoiding or moderating those irritations which 
are almost constant!) applied to the body; as, 

a. The impressions made upon our senses, par- 

ticularly, 
«. Increased heat, whether arising from 
ctot. External heat, or 

js/3. The accumulation of the heat of the 
. body. 

b. The exercise of the body, 

c. The exercise of the mind, 

d. Taking in of aliment, 

e. Particular irritations arising from 
<*. The sense of thirst, 

/3. Crudities, or corrupted humours, in the sto- 
mach, 
y. The preternatural retention of fasces, 
£ A general acrimony of the fluids. 
B Employing certain sedative powers; as, 

a. Cold, 

b. Refrigerants,- the chief of which are, 
». Acids of all kinds, 

/3. Neutral salts, 
y. Metallic salts. 
C. Diminishing the tension and tone of the arterial 
system, by 

a. Blood-letting, 

b. Purging. 



PRACTICE OF PHYSIC. 193 

2. Taking off the spasm of the extreme vessels, by 

A. Internal means; which are, 

a. Those remedies which determine to the sur- 

face, as, 
*• Diluents, 
P Neutral salts, 
v- Sudorifics, 
^ Emetics. 

b. Those remedies named antispasmodics. 

B. External means; as, 

a. Blistering, 

b. Warm bathing. 

II. To remove the causes, or obviate the effects of de- 

bility, by 
1. Supporting and increasing the action of the heart 
and arteries, by 

A. Tonics, as, 
a Cold, 

b. Tonic medicines, which are either, 
* Fossil, as, 

**• Saccharum saturni, &c. or, 
0- Vegetable, as, 
<*<* Peruvian Bark. 

B. Stimulants, as, 

a. Aromatics, &,c. 

b. Wine. 

III. To obviate or correct the tendency of the fluids to 

putrefaction, by 
1. Avoiding the application of putrid or putrescent 
matter, by 

A. Removing the patient from places filled with 
corrupted air. 

B. Correcting the air from which he cannot be 
removed. 

vol. 1. Bb 



194 PRACTICE OF PHYSIC. 

C. Avoiding the accumulation of the patient's own 

effluvia, by 

a. A constant ventilation, 

b. Frequently changing the bed-clothes and 
body-linen. 

D. Removing carefully and speedily all excremen- 

tal matters. 

E. Avoiding animal food, or correcting it. 

2. Evacuating the putrid or putrescent matter already 

present in the body, by 

A. Evacuating frequently the intestines. 

B. Supporting the excretions of perspiration and 
urine, by 

a. Diluents, 

b. Neutral salts. 

3. Correcting the putrid or putrescent matter remain- 

ing in 'the body, by 

A. Diluents, 

B. Antiseptics, 

C. Fixed air. 

4. Resisting farther putrefaction, or obviating its ef- 

fects, by 
Supporting the tone of the vessels, by 
Tonic remedies. 

Sect. II. — Of the cure of Intermittent Fevers.* 

228. It still remains to consider the cure of intermit- 
tent fevers; and, with respect to these, we form also 
three general indications. 



* This section contains an excellent outline of the principles of practice 
in intermitting fever. The indications of cure are judiciously laid down, 
and the general modes of fulfilling them stated with great correctness and 
skill. A brief exposition of one or two points which our author has omitted, 
and a little further detail as to particular remedies, and the times and cir- 



PRACTICE OF PHYSIC. 195 

1. In the time of intermission, to prevent the recur- 
rence nf paroxysms. 

cumstances of their administration, is all, perhaps, that the article wants, 
and all that our limits as an annotator permits us to subjoin. 

We have already stated our belief, that intermitting fever has its seat 
in the stomach. It arises from an irritating impression on that organ. What- 
ever, therefore, during the state of apyrexia makes, on the same organ, a 
counter-impression sufficiently powerful, and continues in it until after the 
period at which the next paroxysm should commence, will prevent that 
paroxysm. This it will do by its effect on the stomach alone, independently 
of its action on the skin, the blood-vessels, or any other part of the system. 
It shatters and destroys the very root of the disease, and hence the branches 
must necessarily wither. It is in this way that all emetic articles act, as 
well as the preparations of copper, arsenic, and opium. It is in the same 
way that spirits of turpentine act, which, when given in large doses during 
the intermission, has often proved effectual in checking intermittents; and 
it is thus, also, that the bark itself acts ; for that remedy is known to pro- 
duce little or no alteration in the state of the blood-vessels. 

Indeed, it is necessarily in the same way that every internal remedy ope- 
rates in the cure of intermittents. Medicines that act on the bowels are not 
very useful in those diseases ; and whatever enters the lacteals is a medi- 
cine no longer. Being completely subdued by the powers of digestion and 
assimilation, it can be regarded only as an article of nutriment ; and, as such, 
aids in continuing, not in altering the existing state of things. 

When the subject is properly considered, the space in the human system 
on which medicines, correctly so called, immediately act, is not very exten- 
sive. It consists of the alimentary canal, the skin, the lungs, and that por- 
tion of the Schneiderian membrane which lines the nares. To no other 
parts can medical substances have immediate access. On these alone, 
therefore, they act, and communicate their influence to other portions of 
the body through the medium of sympathy. 

It is true, that light stimulates the optic, and sound the auditory nerves : 
and, in that way, operate somewhat as medicinal substances. 

It is also true, that venesection acts immediately on the blood-vessels : but 
this is a surgical operation, not a medicinal substance. It produces an un- 
natural state of things ; penetrating through the skin by mechanical force, 
in order to reach the parts that lie beneath it. Nor has venesection the 
slightest tendency to show that any articles can carry their medicinal quali- 
ties into the biood or humours of the body. Still, therefore, the truth re- 
curs, that all medicinal substances, in common with all morbific ones, pro- 
duce their first effect in the form of a local impression on the skin, the ali- 
mentary canal, the lungs, or the nares, and extend their influence through 
the medium of sympathy. 

Impressions made on the stomach very soon reach the skin ; a truth 
which we see daily confirmed by the occurrence of flushes, sweating, and 
eruptions ; while those made on the latter organ as soon make their way to 
the former, giving relief to sickness, nausea, and vomiting. 



196 PRACTICE OF PHYSIC. 

2. Tn the time of paroxysms, to conduct these so as to 
obtain a final solution of the disease. 

3. To take off certain circumstances which might pre- 
vent the fulfilling of the two first indications. 

229. The first indication may be answered in two 
ways: 

1. By increasing the action of the heart and arteries 
some time before the period of accession, and support- 
in? that increased action till the period of the accession 
be over, so as thereby to prevent the recurrence of the 
atony and spasm of the extreme vessels which give oc- 
casion to the recurrence of paroxysms. 

2. Without increasing the action of the heart and ar- 
teries, the recurrence of paroxysms may be prevented, 
by supporting the tone of the vessels, and thereby pre- 
venting atony, and the consequent spasm. 

230. For the purpose mentioned in 229. 1. the ac- 
tion of the heart and arteries may be increased, 

1. By various stimulant remedies, internally given, or 
externally applied, and that without exciting sweat. 

2. By the same remedies, or others so managed as to 
excite sweating, and to support that sweating till the pe- 
riod of accession h< fo some time past. 

3. By nauseating doses of emetics, given about an 
hour before the time of accession, thereby supporting 
and increasing the tone and action of the extreme ves- 
sels. 

231. The tone of the extreme vessels may be sup- 
ported without increasing the action of the heart and 
arteries (229. 2.) by various tonic medicines; as, 

1. Astringents alone. 



Conscious that our views of the operation of medicines differ not a little 
from those of many other writers, we have deemed it expedient to be thus 
explicit in the statement of them, both in relation to the cure of intermitting 
fever and other diseases. 



PRACTICE OF PHYSIC. 197 

2. Bitters alone. 

3. Astringents and bitters conjoined. 

4. Astringents and aromatics conjoined. 

5. Certain metallic tonics. 

6. Opiates. 

Lastly, an impression of horror. 

A good deal of exercise, and as full a diet as the con- 
dition of the patient's appetite and digestion may allow 
of, will be proper during the time of intermission, and 
may be considered as belonging to this head* 

* If an intermittent prove intractable to other remedies, let the patient, 
if an adult, take from two to three grains of opium, either alone or com- 
bined with two grains of ipecacuanha, or a quarter of a grain of tartar emetic, 
about two hours before the commencement of an expected paroxysm. Let 
him, further, go immediately to bed, and attempt the excitement of a sweat 
by the application of heated bricks, or bottles of warm water, to his feet and 
legs, and repeated draughts of sage or balm tea, or some other warm and 
grateful beverage. If a copious sweat appear, which rarely fails to be the 
case, let it be continued until the expiration of the third or fourth hour after 
the time at which the paroxysm should have commenced. By this process 
we have very seldom failed to prevent the paroxysm, which leads with cer- 
tainty to a removal of the disease. 

If horror be the remedy employed, it is of very little consequence in what 
manner it is excited. Ignorant persons and children have been cured of 
their complaint by being shut up in a dark room, in a house believed to be 
haunted, and assailed by certain unusual sounds, for the space of an hour 
before and after the time of an expected paroxysm. 

A slave, some years ago, was cured of intermitting fever, in the state of 
Delaware, by being taken to a certain spot to dig for money believed to have 
been deposited there by the pirate Blackbeard. A negro was reported to 
have been buried alive by the pirate along side of the chest, with orders to 
keep watch over it and its contents until he should reclaim them. 

Our patient, while digging, was under a constant apprehension of seeing 
this sentinel start from the ground in defence of the treasure confided to his 
keeping. Such were the impressions of horror which he experienced from 
this fancy, that the expected paroxysm of his intermittent was prevented. 

The same effect has been obtained by inducing patients of the same de- 
scription to lie down on a tomb-stone, and muttering over them pretended 
ceremonies of incantation. 

It is on the same principle that charms, of whatever kind they may be, 
operate to the cure of intermitting fever. They forcibly impress the mind: 
this, through the medium of the brain, communicates its impression to the 
stomach ; and thus the morbid irritation on that organ, which constitutes 
the root of the disease, is counteracted. 



198 PRACTICE OF PHYSIC. 

232. Of all the tonic remedies mentioned (531.) the 
most celebrated, and perhaps the most certainly effectual, 
is the Peruvian bark, the tonic power of which we have 
endeavoured to demonstrate above, (214.) and have, at 
the same time, explained its use in continued fevers. 

The same observation as made in 216, is especially 
proper in the case of intermittents; and further, with 
respect to these, the following observations or rules are 
offered here. 

1 . That the bark may be employed with safety at any 
period of intermittent fevers, providing that, at the same 
time, there be neither a phlogistic diathesis prevailing 
in the system, nor any considerable or fixed congestion 
present in the abdominal viscera. 

2. The proper time for exhibiting the bark in inter- 
mittent fevers, is during the time of intermission ; and 
where intermissions are to be expected, it is to be ab- 
stained from in the time of paroxysms. 

3. In remittents, though no entire apyrexia occurs, 
the bark may be given during the remissions; and it 
should be given, though the remissions be inconsidera- 
ble, if from the known nature of the epidemic, intermis- 
sions, or considerable remissions are not to be soon 
expected, and that great danger is apprehended from 
repeated exacerbation. 

4. In the case of genuine intermittents, while a due 
quantity of bark is to be employed, the exhibition of it 
ought to be brought as near to the time of accession as 
the condition of the patient's stomach will allow. 

5. In general, in all cases of intermittents, it is not 
sufficient that the recurrence of paroxysms be stopped 
for once by the use of bark; a relapse is commonly to 
be expected, and should be prevented by the exhibition 
of the bark repeated at proper intervals* 

* The propriety of giving an emetic, as preparatory to the administratien 



PRACTICE OF PHYSIC. 199 

233. Our second general indication for conducting 
the paroxysms of intermittent fevers, so as to obtain a 
final solution of the disease, may be answered, 

of the bark, is a practical question, which, however frequently agitated, 
does not appear to be definitively settled. 

The measure, although not in all cases essential to a cure, we believe to 
be in most instances highly useful. Besides their tendency to remove from 
the stomach the topical affection, which we consider as the source of inter- 
mitting fever, emetics discharge from that organ all such adhesive matters 
as might interpose beiween the bark and its internal surface. They procure 
for that article a more immediate access to its villous coat, and thereby add 
to the efficacy of its action. By exciting, moreover, the necessary action on 
the surface of the body, they render the bark a safer remedy: for, to ad- 
minister that medicine when the skin is dry, is a practice that is not war- 
ranted by experience. 

On the whole, therefore, although many cases of intermitting fever are 
cured by the bark alone, without the previous administration of an emetic, 
we are inclined to believe, that, as a general rule, the reverse is the safer and 
more efficacious practice. 

A few doses of the vegetable alkali are said to be an excellent substitute 
for an emetic. This article is supposed to dissolve the mucus adhering to 
the internal surface of the stomach, which an emetic would eject, and in that 
way to bring the bark into immediate contact with its villous coat. 

In the treatment of intermitting fever, all agree that the bark must be 
administered during the period of apyrexia: but there exists a difference of 
opinion as to the particular time of that period, at which it should be given 
in the largest quantity. Dr. Cullen says, towards the close— as near as pos- 
sible to the commencement of the next expected paroxysm. 

In this mode of practice we confess there appears to be not a little reason. 
By means of it the strongest impressions would seem to be made by the 
bark on the stomach at that point of time when it is best calculated to keep 
off the irritation which causes the disease. As opium is known to prevent 
a paroxysm with most certainty when administered only a short time before 
its commencement, why is not the same thing true with regard to the bark? 

Alibert, on the other hand, in his excellent treatise on » Malignant Inter- 
mittents," asserts, that the bark should be given at as great a distance of 
time as possible from the next expected paroxysm. His practice was, there- 
fore, to exhibit it in large and frequent doses at the commencement cf the 
apyrexia, instead of the close ; and, according to his own account, his suc- 
cess was signal. 

This mode of practice is not without both argument and example in its 
favour. 

The bark is not what is denominated a diffusible stimulus. It does not 
operate so speedily as opium ; and. therefore, to produce the necessary 
effect, must be given at a greater length of time before its highest degree of 
action is wanted. Hence, although opium prevents a paroxysm, when ad- 
ministered only two hours before the time of its expected occurrence, bark, 



200 PRACTICE OF PHYSIC. 

1. By exhibiting emetics during the time of the cold 
stage, or at the beginning of the hot. 

to produce the same effect, may require to be given at a much earlier 
period — twelve, perhaps even twenty-four hours before the time of the 
anticipated attack Besides, it is very well known, that the preparations of 
iron, copper,and arsenic, must be exhibited a very considerable time before 
thev produce the full amount of their action on the system 

To avail ourselves of every advantage, our own practice with the bark has 
been, to give it from the beginning to the close of the apyrexia, in doses as 
large and as frequently repeated as the stomach will retain In some cases we 
have administered, with perfect success, from a drachm to a drachm and a 
half every hour, until three ounces have been used 

Alibert and others have practised in a manner still bolder To that phy- 
sician's treatise on ** Malignant Intermittents," we refer our readers for 
much useful information respecting those complaints. 

When the bark disagrees with the stomach, or fails to cure the disease, it 
mav be advantageously combined with certain spices, or other aromatic and 
stimulating substances. In such cases, cloves, ginger, pepper, particularly 
Cayenne pepper, and Virginia snake root, finely pulverized, have been 
found particularly useful Of the four first articles, from three to six, and of 
the last from ten to fifteen grains may be added to each dose of the bark. 
Five or six drops of the elixir of vitriol may be also added with the same in- 
tention. 

Does the bark purge ? combine with each dose of it five drops of lauda- 
num. Does it create costiveness ? add to each dose an equal number of 
grains of rhubarb. 

If, under every form of preparation, the bark fail to cure, give of white ar- 
senic the sixteenth of a grain, combined with a grain or two of ginger four 
or five times a day ; or, of the same article, in the form of Fowler's solution, 
about six drops as often repeated. 

Cuprum vitriolatum and cuprum ammoniacum, in doses of one fourth of a 
grain, repeated three or four times a-day, have been also found successful in 
cases of intermittents that had resisted other remedies. 

It is in the treatment of the quartan ague, that these three last remedies 
have been most successfully employed. 

A remedy now becoming fashionable in Great Britain, in the cure of this 
complaint, and said to be efficacious beyond all others, is the spider's -web, in 
doses of from two to four grains. If taken during the paroxysm, it shortens 
it; if before it, prevents it. 

It is said that no intermittent resists more than two or three repetitions of 
it. It is usually administered in the form of a pill, a short time previously to 
the expected attack. The species of spider whose web is most efficacious 
we are unable to designate. 

Another article which, in the cure of intermittents, has received conside- 
rable reputation abroad, and has also been successfully used, in some in- 
stances, in this eountry, is finely powdered charcoal The dose for an adult 
is a table-spoonful, to be repeated several times a-day. 



PRACTICE OF PHYSIC. 201 

2. By opiates given during the time of the hot stage. 

234. The circumstances which may especially pre- 
vent the fulfilling of those two indications, and there- 
fore give occasion to our third, are a phlogistic diathe- 
sis prevailing in the system, and congestions fixed in the 
abdominal viscera. The first must be removed by 
blood-letting and the antiphlogistic regimen ; the second 
by vomiting and purging. 

Where these measures are not immediately effectual, 
I hold it safer to attempt the cure of the disease by the 
means pointed out in general in 229, rather than by . 
those in article second of the same parag ph. 

The application of tourniquets on the thigh and arm of the opposite sides, 
obstructing the circulation of the blood, some time before the period of the 
expected paroxysm, is said to prove effectual in its prevention. In this 
practice we have had no experience. 

In the treatment of this disease, some of our own indigenous remedies are 
worthy of more attention than they usually receive. 

Of these, we may mention, in particular, the Virginia snake-root, the herb 
centaury, the bark of the dogwood, (both species,) the bark of the willow, 
and that of the root of the liriodendron tulipifera, commonly denominated 
the American poplar. 

These articles are sometimes used in the form of decoction : but they are 
most efficacious when administered in substance in the same mode, and in 
nearly the same doses, with the Peruvian bark. 

In some parts of the country, these remedies are much used by the inhar 
bitants, without medical advice : and, unless where the disease proves un- 
commonly obstinate, rarely fail to effect its removal. 

Cases of intermittents that had baffled every thing else, have yielded, at 
length, to a change of situation, climate, or season, or a change in the con- 
stitution of the patient in his advancement in years. 



VOL. I. CC 



200 PRACTICE OF PHYSIC. 



BOOK II. 

OF INFLAMMATIONS, 

OR PHLEGMASIA. 



CHAPTER I. 

OF INFLAMMATION IN GENERAL. 
Sect. I. — Of the Phenomena of Inflammation. 

235. AV^HEN any part upon the surface of the body is 
affected with unusual redness, heat, pain, and tumour, 
we name the disease an Inflammation or Phlegmasia. 
These symptoms of inflammation are never considera- 
ble, without the whole system being, at the same time, 
affected with pyrexia. 

236. As the external, so likewise the internal parts 
may be affected with inflammation, and we judge them 
to be so, when, together with pyrexia, there is a fixed 
pain in any internal part, attended with some interrup- 
tion in the exercise of its functions. 

237. We judge of the presence of inflammation also 
from the state of the blood drawn out of the veins. When 
the blood, after cooling and concreting, shows a portion 
of the gluten separated from the rest of the mass, and 
lying on the surface of the crassamentum ; as such sepa- 
ration happens in all cases of more evident phlegmasia; 
so, in ambiguous cases, we, from this appearance, joined 
with other symptoms, infer the presence of inflammation. 
At the same time, it must be observed, that as several 



PRACTICE OF PHYSIC. 203 

circumstances in blood-letting may prevent this separa- 
tion of gluten from taking place in blood otherwise dis- 
posed to it; so, from the absence of such appearance, 
we cannot always conclude against the presence of in- 
flammation.* 

238. I cannot easily give any other general history of 
the phenomena of inflammation than what is contained 
in the three preceding paragraphs ; and the variations 
which may take place in its circumstances, will occur 

* Blood exhibits an inflammatory or sizy covering, somewhat in propor- 
tion to the slowness of its coagulation. If it coagulate very slowly, this 
covering will be conspicuous ; if less slowly, less conspicuous ; and if it 
coagulate rapidly, it will not be formed at all. 

Blood, again, coagulates with a rapidity somewhat proportioned to the 
slowness with which it is drawn from the vein. If it be drawn off in a very 
small stream, but more especially by drops, it coagulates almost as soon as 
it falls into the vessel in which it is received. But if it be made to flow in 
a full and bold stream, it does not coagulate for a considerable time. Other 
circumstances, therefore, being alike, it may, in the latter case, exhibit a 
sizy covering, but not in the former. 

In general, blood drawn guttatim, or in a very small stream, rarely exhi- 
bits a thick inflammatory coat : whereas that which flows in a free stream 
exhibits it frequently. 

The form of the vessel also, in which blood is received, makes no incon- 
siderable difference in the appearance of the coagulum If it be wide, flat, 
and shallow, the blood coagulates rapidly, and throws up very little buff; 
but if deep and narrow, it coagulates slowly, and throws up more. 

The blood of a person in perfect health, by being drawn in a free stream, 
received into a narrow vessel, and placed in an atmosphere of a low tempe- 
rature, may be made to coagulate so slowly, as to exhibit a sizy coat of con- 
siderable thickness : while, on the contrary, that of a patient labouring under 
an inflammatory disease, by being differently treated, will manifest no size. 

The theory of the formation of the sizy covering of blood appears to be as 
follows. 

That fluid is known to consist of three parts, the coagulating lymph, the 
serum, and the red globules, of which the latter are the heaviest in propor- 
tion to their bulk. 

If the blood coagulate immediately after being drawn from the vein, the 
coagulating lymph, in contracting, arrests the red globules, and holds them 
so intimately mingled with itself, as to exhibit an appearance uniformly 
florid. But if it be longer in coagulating, the red globules, being the 
weightiest portion, sink towards the bottom of the vessel, while the- blood is 
yet liquid, leaving the white or buff coloured lymph at the top. This lymph 
coagulating, forms the sizy covering of which we are speaking. 



204 PRACTICE OF PHYSIC. 

to be more properly taken notice of under the several 
heads of the particular genera and species to be hereaf- 
ter mentioned. I proceed, therefore, to inquire into the 
proximate cause of inflammation in general. 

Sect. II. — Of the Proximate Cause of Inflammation* 

239. The phenomena of inflammation (235.) all con- 
cur in showing that there is an increased impetus of 
the blood in the vessels of the part afFected; and as, at 

• Dr. Cullen's theory of inflammation is confused and unsatisfactory. Be- 
ing, much of it, conjectural, and, as a whole, altogether incompetent to ex- 
plain the phenomena of the disease ; it is now, we believe, abandoned by 
every pathologist. Instead, therefore, of a useless display of argument 
against an hypothesis which no longer misleads the minds of physicians, we 
think it better to lay before our readers as succinct a view as possible, of 
what appears to us to be the least objectionable theory of inflammation. We 
say the least objectionable, for it must be acknowledged that there still exist 
objections to every theory. 

Instead of being " increased," it appears from experiment, and we think 
also from reason, that the " impetus of the blood" in an inflamed part is 
necessarily diminished. On no other ground can the leading and character- 
istic phenomena be explained. 

A congestion of blood in the vessels of the part affected, constitutes an 
essential condition of ever}' inflammation. It is a fundamental symptom, 
without which the disease can have no existence, in as much as it operates 
as the cause of other symptoms. 

But without a diminished impetus — a remora or obstruction of some kind — 
no topical congestion can take place ; much less can it occur under an in- 
creased impetus. Were the impetus in every part of the vessels the same, 
the blood would be equally diffused throughout the whole : were it in any 
part increased, the blood would appear in that part in a diminished propor- 
tion. From the very nature of the case, the impetus and the quantity of 
blood in any^ given part, must always maintain towards each other an inverse 
ratio : if the impetus be preternaturally great, the quantity will be preter- 
naturally small, and the reverse. 

For the illustration of our position we will resort to a comparison. The 
current of the blood through the veins is aptly enough represented by the 
current of a river within its banks. They both consist of a fluid in motion. 
In what part of a river, then, are we accustomed to find an accumulation of 
its waters? Surely not at its rapids, where the impetus of the water is in- 
creased, and the stream, of course, preternaturally shallow ; but at some flat 
and level spot, where their impetus is weak and their movement sluggish : 
it is there alone, that, within a given space, the waters exist in a supera- 
bundant quantity. 



PRACTICE OF PHYSIC. 205 

the same time, the action of the heart is not always evi- 
dently increased, there is reason to presume, that the 

Bat as well might we expect to find an accumulation of water within the 
declivity of the rapids of a river, as a congestion of blood in any portion of 
the vessels where its impetus is increased. 

Thus far does reason support us in our position. Nor is the result of 
experiment and observation less favourable to us. When examined with a 
microscope, the movement of the blood through the vessels of an inflamed 
part i3 found to be preternaturally slow. In cases of great violence it is 
scarcely perceptible. So stagnant does the blood become in these instances, 
as to exchange its arterial for a venous character, communicating to the part 
affected somewhat of a purple instead of a florid colour. So far is the im- 
petus of the blood, then, from bearing a direct proportion to the violence of 
inflammation, that the reverse is true — the inflammation is high in proportion 
as the remora is great and obstinate. Hence a purplish appearance, in 
topical inflammation, gives reason to apprehend an approaching gangrene. 

Again : the nature of the causes which induce inflammation, is such as 
convinces us that they diminish rather than increase the powers of action 
in the part affected. As far as we know and can speak of them with cer- 
tainty, they are cold, mechanical violence, and chemical irritants. Under 
the latter head we include burning, or the action of fire. 

But neither of these can produce inflammation until it has so far injured 
the part affected, as necessarily and very obviously to diminish its powers. 
On no principles whatever can the long continued application of intense cold, 
a severe contusion, or a wound, be supposed to add to the powers of action 
in the injured part. On the other hand, the patient himself is sensible, at 
the time, of the reduction of these powers — sensible that the functions of 
the part are weakened. The same thing may be said with regard to the ap- 
plication of fire. More promptly and certainly, perhaps, than any thing 
else, does it diminish the powers of action. For the truth of this, we can- 
not do better than refer to the experience of those who have been subject 
to the injuries of which we are speaking. Besides, had we a wish to invi- 
gorate the powers of action in any part of the body, would we, for the pur- 
pose, apply to that part intense heat or cold, mechanical violence or strong 
chemical irritants? It is scarcely necessary to reply that we would not. The 
agents we would employ would be of a different description. It may be laid 
down as a physical axiom, that whatever gives severe pain tends to dimi- 
nish power in the part affected. It exhausts the vital energy, which is itself 
the source of both action and power. 

Had we leisure to examine analytically the nature and operation of the 
remedies best adapted to the cure of topical inflammation, we should find 
them to be such as are calculated to increase, not to diminish, the action of 
the vessels. With the exception of blood-letting local and general, they are 
all of a stimulating character. Cold and heat, blistering and spirits of tur- 
pentine, are included in the number. In this case, even blood-letting itself 
would seem to operate as an indirect stimulant. Besides relieving the vessels 
of the inflamed part from the irritation of a portion of superabundant bldod, 



206 PRACTICE OF PHYSIC. 

increased impetus of the blood in the particular part is 
owing especially to the increased action of the vessels 
of that part itself. 

240. The cause of this increased action in the ves- 

it leaves them at liberty to contract by taking off that fulness and tension, 
which, by inducing in them a paralysis, prevents their action 

Were we ourselves to attempt to lay down a theory of inflammation, it 
would be somewhat as follows : 

We would, as a preliminary, observe, what every physiologist already 
knows, that the circulation of the blood through the capillary vessels, in- 
stead of depending on the impetus communicated to it by the heart, is 
effected, if not entirely, at least in a great measure, by the action of the ves- 
sels themselves. Hence a paralysis, <<r want of power in an\ portion of them, 
produces, of necessity, in that portion, a stagnation of the blood 

By the operation of some irritating agent, the presence of v bich we cannot 
always discover, this paralysis or want of the power of action takes place in 
the capillaries of a certain organ or part. The consequence is, a stagnation 
of the blood in that part, because there is nothing to keep it in motion. But 
the evil does not terminate here. The action of the heart and larger arte- 
ries continuing, and being even augmented by means of the existing irrita- 
tion, what was at first a mere stagnation in the capillaves, becomes an accu- 
mulation, in consequence of the blood that is constantly thrown into them. 
This blood is perceived to be arterial Hence the redntss, tension, pain and 
swelling, which constitute the leading phenomena of inflammation. To re- 
move these phenomena, provided the disease be local, nothing is neces- 
sary but the excitement of action in the affecn-d vessels, by mean.-, of which 
the blood may be forced along in its usual channels. If the disease be gene- 
ral, and the vis a tergo increased, blood-letting is requisite. 

In case the inflammation be phlegmonous, and the natural action of the 
vessels cannot be restored, in time to prevent their own rupture or the death 
and mortification of the part, they assume, by the powers of nature, a new 
action, in order to free themselves from their superabundant contents They 
put on a glandular character, and secrete pus. In this way they discharge 
by secretion the blood which, had they been capable of action, would have 
passed through them by ordinary circulation. 

From the foregoing representations it appears, that, to produce local in- 
flammation, nothing is necessary but an irritation connected with a want of 
the power of action in a portion of the capillary vessels, the force of the 
circulation throughout the system remaining unaltered. To render this in- 
flammation general, the impetus of the circulation, and consequently the 
force, of the vis a tergo, in relation to the topical affection, must be increased. 

Dr. Cullen, convinced himself that a remora or obstruction to the free and 
rapid passage of the blood through the vessels of an inflamed part does 
take place, has attributed this phenomena to the influence of spasm. In his 
view, therefore, of the mere mechanism of inflammation, he appears to have 
been right ; in that of its proximate cause, we think he was wrong. 



PRACTICE OF PHYSIC. 207 

sels of a particular part is, therefore, what we are to con- 
sider as the proximate cause of inflammation. 

In many cases, we can manifestly perceive, that in- 
flammation arises from the application of such stimu- 
lant substances to the part. When the application of 
such stimulants, therefore, is evident, we seek for no 
other cause of inflammation: but as, in many cases, 
such application is neither evident, nor, with any pro- 
bability, to be supposed, we must, in such cases, seek 
for some other cause of the increased impetus of the 
blood in the vessels of the part. 

241. Many physicians have supposed, that an ob- 
struction of the extreme vessels, any how produced, 
may prove a cause of inflammation; and particularly, 
that this may arise from an obstruction formed by a mat- 
ter stopping up these vessels. But many difficulties at- 
tend this doctrine. 

1. The opinion seems chiefly to have arisen from the 
appearance of the blood described in (237.) when the 
separated gluten was considered as a preternatural and 
morbid matter; but we now know very certainly, that 
this gluten is constantly a constituent part of the human 
blood; and that it is only a peculiar separation of the 
parts of the blood that happens in consequence of in- 
flammation and some other circumstances, which gives 
occasion to the appearance that was falsely considered 
as a mark of a morbid lentor in the blood. 

2. There are no experiments directly in proof of a 
preternatural lentor prevailing in the mass of blood; nor 
is there any evidence of certain parts of the blood oc- 
casionally acquiring a greater density and force of co- 
hesion than ordinary; neither is there any proof of the 
denser or more coherent parts being present in the mass 
of blood, in such greater proportion than usual, as to 
occasion a dangerous spissitude. The experiments of 



208 PRACTICE OF PHYSIC. 

Dr. Brown Langrish on this subject afford no conclu- 
sion, having been made on certain parts of the blood 
separated from the rest, without attending to the cir- 
cumstances of blood-letting, which very much alter the 
state of the separation and concretion of the blood 
drawn out of the veins. 

3. The supposition of a preternatural lentor or vis- 
cidity of the blood, is not well founded; for it is proba- 
ble, that nature has specially provided against a state of 
the fluids, so incompatible with the exercise of the most 
important functions of the animal economy. While mo- 
tion continues to prevent any separation of parts, and 
heat continues to preserve the fluidity of the more vis- 
cid, there seems to be always so large a proportion of 
water present as to give a sufficient fluidity to the 
whole. I must own that this is not absolutely conclu- 
sive; but I still repeat it, as giving a probability to the 
general argument. 

4. In the particular case of inflammation, there are 
several circumstances which render it probable that the 
blood is then more fluid than usual. 

5. I presume that no such general lentor, as Boer- 
haave and his disciples have supposed, does ever take 
place; because if it did, it must show more considera- 
ble effects than commonly appear. 

6. Besides the supposition of an obstructing lentor, 
physicians have supposed, that an obstruction may be 
formed by an impermeable matter of another kind, and 
that such an obstruction may also be the cause of in- 
flammation. This supposition is what is well known in 
the schools under the title of an error loci; but it is an 
opinion that I cannot find to be at all probable; for the 
motion of the blood in the extreme vessels is so weak 
and slow, as readily to admit a retrograde course of it; 
and therefore, if a particle of blood should happen to 



PRACTICE OF PHYSIC. 209 

enter a vessel whose branches will not allow of its pas- 
sage, it will be moved backwards, till it meet with a ves- 
sel fit for transmitting it; and the frequent ramifications 
and anastomoses of the extreme arteries are very fa- 
vourable to this. I must own, indeed, that this argu- 
ment is not absolutely conclusive; because I allow it to 
be pretty certain, that error loci does actually upon oc- 
casion happen; but for the reasons I have given, it is 
probable that it seldom happens, and is therefore rarely 
the cause of inflammation: or if it be, that it is not 
merely by the obstruction that it produces; as, among 
other reasons, I conclude particularly from the follow- 
ing argument. 

7. Though an obstruction should be supposed to take 
place, it will not be sufficient for producing the effects, 
and exhibiting the phenomena, that appear in inflam- 
mation. The theory that has been commonly employed 
on this occasion is by no means satisfying; and, in fact, 
it appears, from many observations and experiments, 
that considerable obstructions may be formed, and may 
subsist, without producing the symptoms of inflamma- 
tion. 

242. Obstruction, therefore, from a matter stopping 
up the vessels, {Gaub. Pathol. 249. i.) is not to be con- 
sidered as the primary cause of inflammation; but at 
the same time, it is sufficiently probable, that some de- 
gree of obstruction does take place in every case of in- 
flammation. The distention, pain, redness and tumour, 
attending inflammation, are to be explained only by sup- 
posing, that the extremities of the arteries do not readily 
transmit the unusual quantity of blood impelled into 
them by the increased action in the course of these ves- 
sels. Such an obstruction may be supposed to happen 
in every case of an increased impetus of the bloo but 
it is probable, that in the ca-e of inflammation, theie is 

VOL. i. d d 



210 PRACTICE OF PHYSIC. 

also a preternatural resistance to the free passage of the 
fluids. 

243. From the doctrine of fever, we are led to be- 
lieve, that an increased action of the heart and arteries 
is not supported for any length of time, by any other 
means than a spasm affecting the extreme vessels; and 
that the same spasm takes place in inflammation seems 
likely, because that every considerable inflammation is 
introduced by a cold stage, and is accompanied with 
that and other, circumstances of pyrexia. It seems also 
probable, that something analogous to this occurs even 
in the Case of those inflammations which appear less 
considerable, and to be purely topical. 

244. From all this the nature of inflammation may 
in many cases be explained in the following' manner. 
Some causes of inequality in the distribution of the blood 
may throw an unusual quantity of it upon particular 
vessels, to which it must necessarily prove a stimulus. 
But, further, it is probable, that to relieve the conges- 
tion, the vis medicatrix nalurce increases still more the 
action of these vessels; and which, as in all other febrile 
diseases, it affects by the formation of a spasm on their 
extremities. 

245. A spasm of the extreme arteries, supporting an 
increased action in the course of them, may therefore 
be considered as the proximate cause of inflammation; 
at least, in all cases not arising from direct stimuli ap- 
plied; and even in this case the stimuli may be supposed 
to produce a spasm of the extreme vessels. 

24G. That, in inflammation, th< re is the concurrence 
of a constriction of the extreme vessels, with an in- 
creased action in the other parts of them, seems pro- 
bable, from the consideration of Rheumatism. This is 
a species of inflammation which is often manifestly pro- 
duced, either by cold applied to over-distended vessels, 



PRACTICE OF PHYSIC. 211 

or by causes of an increased impetus, and over-disten- 
tion in vessels previously constricted. Hence the dis- 
ease especially appears at seasons liable to frequent and 
considerable vicissitudes of heat and cold. 

To this we may add, that the parts of the body most 
frequently affected with inflammation, are those expos- 
ed, both to over-distention, from a change in the distri- 
bution of the fluids, and, at the same time, to the imme- 
diate action of cold. Hence, quinsies, and pneumonic 
inflammations, are more frequent than any others. 

247. That a spasm of the extreme vessels takes place 
in inflammation, is to be further presumed from what is 
at the same time the state of the whole arterial system. 
In every considerable inflammation, though arising in 
one part only, an affection is communicated to the whole 
system, in consequence of which an inflammation is 
readily produced in other parts beside that first affected. 
This general affection is well known among physicians, 
under the name of the diathesis phlogistica. It 
appears most commonly in persons of the most rigid fi- 
bres: is often manifestly induced by the tonic or astrin- 
gent powers of cold; is increased by all tonic and stimu- 
lant powers applied to the body; is always attended with 
a hardness of the pulse; and is most effectually taken 
off by the relaxing power of blood-letting. From these 
circumstances, it seems probable, that the diathesis phlo- 
gistica consists in an increased tone, or contractility, 
and perhaps in an increased contraction of the muscu- 
lar fibres of the whole arterial system. Such a state of 
the system seems often to arise, and subsist for some 
time, without the apparent inflammation of any particu- 
lar part; but such a state of the system renders it likely, 
that a spasm may at the same time readily arise in any 
of the extreme vessels, and a particular inflammation be 
there produced. It does, however, appear, also,, that 



212 PRACTICE OF PHYSIC. 

the general diathesis frequently arises from inflamma- 
tion begun in a particular part. 

248. I have thus endeavoured, in the case of inflam- 
mation, to explain the state of the whole system, as well 
as that of the part more particularly affected. The lat- 
ter I have considered as when in its first formation; but 
aft' r it has subsisted for some time, various changes 
take place in the part affected; and of these I must now 
take notice. 

Sect. III. — Of the Terminations of Inflammation. 

249. If an inflammation be cured while the state and 
texture of the part remain entire, the disease is said to 
be terminated by resolution. 

This happens when the previous congestion and 
spasm have been in a moderate degree, and the increased 
impetus of the blood has been sufficient to overcome 
the spasm, to dilate the vessels and to remove the con- 
gestion so that the part is restored to its ordinary and 
healthy state. 

A resolution takes place also when the increased im- 
petus of the fluids has produced an increased exhala- 
tion into the adjoining cellular texture, or an increased 
excretion in some neighbouring part, and has thereby 
relaxed the spasm, and relieved the congestion, in the 
vessels of the part more particularly affected. 

Lastly, a resolution may take place, when the increas- 
ed impetus of the blood in the whole system occasions 
an evacuation, which, though in a distant part, may 
prove sufficient to take off the phlogistic diathesis of the 
whole system, and thereby relieve the congestion and 
spasm of the particular part affected by inflammation. 

250. The tumour which appears in inflammation may 
be imputed in part to the congestion of fluids in their 



PRACTICE OF PHYSIC. 213 

proper vessels ; but is owing chiefly to an effusion of 
matter into the adjoining cellular texture; and, accord- 
ingly, tumours seldom appear but in parts adjoining to 
a lax cellular texture. If in this case, the matter effused 
be only a larger quantity of the ordinary exhaling fluid, 
this, when the free circulation in the vessels is restored, 
will be readily absorbed, and the state of the part will 
become the same as before. But if the increased im- 
petus of the blood in an inflamed part, dilate the exha- 
lant vessels to such a degree, that they pour out an entire 
serum, this will not be so readily reabsorbed; and, from 
the experiments of Sir John Pringle, and especially 
from those of Mr. Gaber, Miscell. Taurin. Vol. II., we 
learn, that the serum, under stagnation, may suffer a 
particular change, by having the gluten present in it 
changed into a white, opaque, moderately viscid, mild 
liquor, which we name pus. When this change takes 
place in the inflamed part, as it is at the same time at- 
tended with an abatement of the redness, heat, and 
pain, which before distinguished the inflammation, so 
the disease is said to be terminated by suppuration; 
and an inflamed part, containing a collection of pus, is 
called an abscess.* 

251. In inflammation, the tendency of it to suppura- 
tion may be discovered by the long continuance of the 

* Pus is not produced by a mere change in an effused and stagnant por- 
tion of fluid. It is now known to be the result of morbid glandular action. 
It is as genuine a secretion from the blood as bile or urine, saliva or the pan- 
creatic juice. As already intimated, it is formed by the glandular action of 
the capillaries, which nature, in her wisdom and resources, enables them to 
assume, in order that they may relieve themselves from the superabundance 
of blood which oppresses them. 

For a correct theory of the formation of pus, we are indebted to an Ameri- 
can physician — the late Dr. Morgan of Philadelphia. For the Doctor's views 
on this subject, see his excellent Inaugural Dissertation published in Edin- 
burgh, in the Latin tongue, in the year 1765. For the honour of American 
medical literature, this essay ought to be republished, and every physician 
of our country should qualify himself to read it in the language in which it 
appears. 



214 PRACTICE OF PHYSIC. 

inflammation, without the symptoms of resolution; by 
some remission of the pain of distention; by the pain 
becoming of a throbbing kind, more distinctly connect- 
ed with the pulsation of the arteries being fuller and 
softer; and often by the patient's being frequently af- 
fected with cold shiverings. The period at which this 
takes place is not determined, but may be sometimes 
sooner, sometimes later. When the tendency is deter- 
mined, the time necessary to a complete suppuration is 
different in different cases. 

When pus is completely formed, the pain in the part 
entirely ceases, and a weight is felt in it. If the collec- 
tion be formed immediately under the skin, the tumour 
becomes pointed, the part becomes soft, and the fluctu- 
ation of the fluid within can commonly be perceived; 
while at the same time, for the most part, the redness 
of the skin formerly prevailing is very much gone. 

252. In abscesses, while the pus is formed of one part 
of the matter which had been effused, the other and 
thinner parts are reabsorbed, so that in the abscess, 
when opened, a pus alone appears. This pus, how- 
ever, is not the converted gluten alone; for the conver- 
sion of this being the effects of a particular fermenta- 
tion, which may affect the solid substance of the part, 
and perhaps every solid of animal bodies; so it most 
readily, and particularly, affects the cellular texture, 
eroding much of it, which therein, becomes a part of 
the pus. It generally happens also, that some of the 
smaller red vessels are eroded, and thereby some red 
blood often appears mixed with the pus in abscesses. 
Upon the whole, the internal surface of an abscess is to 
be considered as an ulcerated part.* 

* In cases of suppuration there occurs no erosion of the solid parts by 
means of either a fermentation, or the action of an acrimonious fluid pro- 



PRACTICE OF PHYSIC. 215 

253. This account of suppuration explains, why an 
abscess, when formed, may either spread into the cellu- 
lar texture of the neighbouring parts; or by eroding the 
incumbent teguments, be poured out upon the surface 
of the body, and produce an open ulcer. 

25 4. We have here given the idea of abscess as a 
collection of matter following inflammation; but the term 
has been applied to every collection of matter effused, 
and changed by stagnation in an enclosed cavity. 

The matter of abscesses, and of the ulcers following 
them, is various, according to the nature of what is 
effused, and which may be, 

1. A matter thinner than serum. 

2. An entire and pure serum. 

3. A quantit) of red globules. 

4. A matter furnished by particular glands seated in 
the part. 

5. A mixture of matters from different sources, 
changed by peculiar fermentation. 

It is the second only which affords a proper pus; the 
effusion whereof, whether in suppurating parts or ulcers, 
seems to be the peculiar effect of an inflammatory state 
of the vessels; and for this reason it is, that, when ulcers 
do not produce a proper pus, a circumstance always 
absolutely necessary to their healing, we, in many cases, 
bring the ulcers to a state of proper suppuration, by 
the application of stimulants exciting inflammation, such 
as balsams, mercury, copper, &c. 

255. When the matter effused into the cellular tex- 
ture of an inflamed part is tainted with a putrid fer- 

dticed. The removal of the solid matter which takes place in ulceration is 
to be attributed entirely to the action of the absorbents. 

We might here remark, that there does not exist a more plain and striking 
manifestation of 'he sanative powers of nature, than that of internal ulcera- 
tion always travelling towards the surface of the body, so as to discharge the 
contents of abscesses through the skin. 



216 PRACTICE OF PHYSIC. 

merit, this produces in the effused matter a state ap- 
proaching more or less to that of putrefaction. When 
this is in a moderate degree, and affects only the fluids 
effused, with the substance of the cellular texture, the 
part is said to be affected with gangrene; but if the 
putrefaction affect also the vessels and muscles of the 
part, the disease is said to be a sphacelus. 

256. A gangrene, and its consequences, may arise 
from a putrid ferment diffused in the mass of blood, and 
poured out with the serum effused ; which it operates 
upon more powerfully while the serum is stagnant, and 
retained in the heat of the body: bnt it may also arise 
from the peculiar nature of the matter effused being 
disposed to putrefaction ; as particularly seems to be the 
case of the red globules of the blood effused in a large 
quantity. In a third manner also, a gangrene seems 
frequently to arise from the violent excitement of the 
inflammation destroying the tone of the vessels; where- 
by the whole fluids stagnate and run into putrefaction, 
which taking place in any degree, destroys still further 
the tone of the vessels, and spreads the gangrene.* 

257. In inflammation, the tendency to gangrene may 
be apprehended from an extreme violence of pain and 
heat in the inflamed part, and from a great degree of 
pyrexia attending the inflammation. 

The actual coming on of gangrene may be perceived 
by the colour of the inflamed part changing from a clear 
to a dark red; by blisters arising upon the part; by the 
part becoming soft, flaccid, and insensible; and by the 
ceasing of all pain while these appearances take place. 

As the gangrene proceeds, the colour of the part be- 
comes livid, and by degrees quite black; the heat of the 

* It is to a -want of sufficient vitality in the solids, and not to any " putrid 
ferment" in the blood, that we are to look as the source of gangrene and 
sphacelus. We repeat, for the last time in our annotations, that no putrid 
ferment ever exists in the blood. 



PRACTICE OF PHYSIC. 2\1 

part entirely ceases; the softness and flaccidity of the 
part increase; it loses its consistence, exhales a cadave- 
rous smell, and may be then considered as affected with 
sphacelus. 

258. Gangrene is thus a third manner in which in- 
flammation terminates; and the schools have commonly 
marked a fourth termination of inflammation; which is, 
by a scirrhus, or an indolent hardness of the part for- 
merly affected with inflammation. This, however, is a 
rare occurrence, and does not seem to depend so much 
upon the nature of inflammation, as upon the circum- 
stances of the part affected. It is in glandular parts 
chiefly that scirrhosity is observed; and it is probably 
owing to the parts readily admitting a stagnation of the 
fluids. [ have observed, that inflammation seldom in- 
duces scirrhus; but that this more commonly arises 
from other causes; and when inflammation supervenes, 
which it is sooner or later apt to do, it does not so com- 
monly increase, as change the scirrhosity into some 
kind of abscess. From these considerations it does not 
seem necessary to take any further notice of scirrhus 
as a termination of inflammation. 

259. There are, however, some other terminations of 
inflammation, not commonly taken notice of, but now 
to be mentioned. 

One is, by the effusion of a portion of the entire 
mass of blood, either by means of rupture or of anas- 
tomosis, into the adjoining cellular texture. This hap- 
pens especially in inflammations of the lungs, where the 
effused matter, by compressing the vessels, and stopping 
the circulation, occasions a fatal suffocation: and this is 
perhaps the manner in which pneumonic inflammation 
most commonly proves fatal. 

260. Another kind of termination is, that of certain 
inflammations on the surface of the body, when there 

vol. i. e e 



218 PRACTICE OF PHYSIC. 

is poured out under the cuticle a fluid, which being too 
gross to pass through its pores, therefore separates it 
from the skin, and raises it up into the form of a vesicle 
containing the effused fluid; and by which effusion the 
previous inflammation is taken off. 

261. Besides these already mentioned, I believe there 
is still another manner in which inflammation terminates. 
When the internal parts are affected with inflammation, 
there seems to have been almost always upon their sur- 
face an exudation, which appears partly as a viscid con- 
cretion upon their surface, and partly as a thin serous 
fluid effused into the cavities in which the inflamed vis- 
cera are placed. Though we have become acquainted 
with these appearances only, as very constantly accom- 
panying those inflammations which have proved fatal, it 
is, however, probable, that like circumstances may have 
attended those which have terminated by resolution, and 
may have contributed to that event. It is in favour of 
this supposition that there are instances of pneumonic 
inflammation terminating in a hydrothorax.* 

Sect. IV. — Of the Remote Causes of Inflammation. 

262. The remote causes of inflammation may be re- 
duced to five heads. 

1. The application of stimulant substances, among 
which are to be reckoned the action of fire, or burn- 
ing. 

2. External violence operating mechanically in 
wounding, bruising, compressing, or overstretching the 
parts. 

* Real Dropsy may be safely represented as one of the modes in which 
inflammation occasionally terminates. I'erhaps hydrothorax seldom arises 
from any other source- To the same cause may we attribute ascites, in 
every instance, where the fluid effused is gelatinous and viscid; and in 
many where it is perfectly serous, the character of the disease is evidently 
inflammatory. Hydrocele is also the result of inflammation. 



PRACTICE OF PHYSIC. 219 

3. Extraneous substances, lodged in any part of the 
body, irritating by their chemical acrimony or mecha- 
nical form, or compressing by their bulk or gravity. 

4. Cold, in a certain degree, not sufficient immedi- 
ately to procure gangrene. 

5. An increased impetus of the blood determined to 
a particular part. 

It will not be difficult to understand how these re- 
mote causes, singly, or in concurrence, produce the 
proximate cause of inflammation.* 

263. It does not appear, that in different cases of in- 
flammation, there is any difference in the state of the 
proximate cause, except in the degree of it; and though 
some difference of inflammation may arise from the 
difference of the remote causes, yet this is not neces- 
sary to be taken notice of here; because the different 
appearances which attend different inflammations may 
be referred, for the most part, to the difference of the 
part affected, as will appear when we shall consider 
the several genera and species marked in the Nosology. 
When I come to treat of these, I shall find a more pro- 
per occasion for taking notice of the different states of 
the proximate, or of the differences of the remote cause, 
than by treating of them in general here.f 

* Our author had better, perhaps, have said, in general terms, that inflam- 
mation is produced by the operation of certain irritants — it being impossible 
for it to arise from any other source — and then proceeded to enumerate and 
classify these irritants, according to their affinities. In his present arrange- 
ment there is confusion and tautology, certain articles included under his 
second and third heads being substantially the same. 

In his exposition of his fifth head he is lame and defective. If there exist 
"an increased impetus of the blood determined to a particular part," it must 
be necessarily as the result of some irritating agent. To allege the contrary, 
would be to admit the existence of an effect without a cause. 

j- Inflammations differ materially in their character according to the causes 
that produce them. Those arising from the action of fire and frost, while 
they are unlike all others, are also marked by a very striking difference be- 
tween themselves. Burns and chilblains may be regarded in the light of 



22Q PRACTICE OF PHYSIC. 

Sect. V. — Of the Cure of Inflammation. 

264. The indications of cure in inflammation are 
different, according as it still may be capable of resolu- 
tion, or may have taken a tendency to the several other 
terminations above mentioned. As the tendency to 
these terminations is not always immediately evident, it 
is always proper, upon the first appearance of inflam- 
mation, to attempt the cure of it by resolution. For 
this purpose, the indications of cure are, 

1. To remove the remote causes, when they are evi- 
dent, and continue to operate. 

2. To take off the phlogistic diathesis affecting either 
the whole system, or the particular part. 

3. To take off the spasm of the particular part, by 
remedies applied either to the whole system, or to the 
part itself. 

265. The means of removing the remote causes will 
readily occur, from considering the particular nature and 
circumstances of the different kinds. Acrid matters must 
be removed, or their action must be prevented, by the 
application of correctors and demulcents. Compressing 
and overstretching powers must be taken away; and, 
from their several circumstances, the means of doing so 
will be obvious.* 

266. The means of taking off the phlogistic diathe- 
sis of the system, are the same with those for moderat- 
ing the violence of reaction in fever, which are men- 
specific affections. They put on appearances and require modes of treat- 
ment different from those of other inflammations. They produce, also, in 
those affected by them, different sensations. 

* If the irritating cause be of an alkaline nature, neutralize it by an acid ; 
and if of an acid character, neutralize it by an alkali. But if it be neither 
acid nor alkaline, diluents and demulcents may be employed with the pros- 
pect of advantage. 



PRACTICE OF PHYSIC. 221 

tion^d and treated of (from 127. to 149.) and therefore 
need not be repeated here. I only observe, that in the 
use of those remedies, there is less occasion for any re- 
serve than in many cases of fever; and more particu- 
larly, that topiral bleedings are here particularly indi- 
cated and proper. 

267. The means of taking off the spasm of the par- 
ticular part are nearly the same as those mentioned 
above, for taking off the spasm of the extreme vessels 
in the case of fever, and which are treated of (from 1 50 
to 200.) Only it is observed here, that some of these 
are here especially indicated, and that some of them are 
to be directed more particularly to the part especially 
affected, the. management of which will be more pro- 
perly considered, when we shall treat of particular in- 
flammations. 

26S. When a tendency to suppuration (251.) is dis- 
tinctly perceived, as we suppose it to depend upon the 
effusion of a fluid which cannot be easily reabsorbed, so 
it becomes necessary that this fluid be converted into 
pus, as the only natural means of obtaining its evacua- 
tion; and as the effusion is, perhaps, seldom made with- 
out some rupture of the vessels, to the healing of which 
a pus is absolutely necessary; so, in the case of a ten- 
dency to suppuration, the indication of cure always is, 
to promote the production of a perfect pus as quickly 
as possible. 

269. For this purpose, various remedies, supposed to 
possess a specific power, have been proposed; but I can 
perceive no such power in any of them ; and in my opi- 
nion, all that can be done is, to favour the suppuration 
by such applications as may support a proper heat in 
the part, as by some tenacity may confine the perspira- 
tion of the part, and as, by an emollient quality, may 



222 PRACTICE OF PHYSIC. 

weaken the cohesion of the teguments, and favour their 
erosion.* 

210. As, in the case of certain effusions, a suppura- 
tion is not only unavoidable, but desirable, it may be sup- 
posed, that most of the means of resolution formerly 
mentioned should be avoided; and accordingly our prac- 
tice is commonly so directed. But, as we observe, on 
the one hand, that a certain degree of increased impe- 
tus, or of the original circumstances of inflammation, is 
requisite to produce a proper suppuration; so it is then 
especially necessary to avoid those means of resolution 
that may diminish too much the force of the circulation. 
And as, on the other hand, the impetus of the blood, 
when violent, is found to prevent the proper suppuration; 
so, in such cases, although a tendency to suppuration 
may have begun, it may be proper to continue those 
means of resolution which moderate the force of the 
circulation. 

With respect to the opening of abscesses, when com- 
pletely formed, I refer to the writings on surgery. 

271. When an inflammation has taken a tendency to 
gangrene, that event is to be prevented by every possible 
means; and these must be different, according to the na- 
ture of the several causes occasioning that tendency, as 
may be understood from what has been already said of 
them. After a gangrene has, in some degree, taken 
place, it can be cured only by the separation of the dead 



* The mode of practice best calculated to promote suppuration, is the ap- 
plication and frequent renewal of large, soft, and warm poultices, composed 
of materials retentive of heal. Oily and mucilaginous substances should 
enter largely into the composition of these articles. No better poultice, 
perhaps, can be formed, than that which consists of proper proportions of 
light bread and milk, flaxseed, and olive oil or fresh lard. The diet and re- 
gimen must be suited to the state and habits of body of the diseased — ge- 
nerous and free, if great debility prevail; and the reverse, in cases of gene- 
ral inflammatory action. 



PRACTICE OF PHYSIC. 223 

from the living parts. This, in certain circumstances, 
can be performed by the knife, and always most pro- 
perly, when it can be so done. 

In other cases, it can be done by exciting a suppura- 
lory inflammation on the verge of the living part, whereby 
its cohesion with the dead may be every where broken 
off, so that the latter may fall off by itself. While this 
is doing, it is proper to prevent the further putrefaction 
of the part, and its spreading wider. For this purpose, 
various antiseptic applications have been proposed: but 
it appears to me, that while the teguments are entire, 
these applications con hardly have any effect; and, there- 
fore, that the fundamental procedure must be to scarify 
the part so as to reach tlje living substance, and by the 
wounds made there, to excite the suppuration required. 
By the same incisions also, we give access to antisep- 
tics, which may both prevent the progress of the putre- 
faction in the dead, and excite the inflammation neces- 
sary on the xer^e of the living part.* 

212. When the gangrene proceeds from a loss of tone; 
and when this, communicated to the neighbouring parts, 
prevents that inflammation which, as I have said, is ne- 
cessary to the separation of the dead part from the liv- 
ing; it will be proper to obviate this loss of tone by tonic 
medicines given internally; and, for this purpose, the 
Peruvian bark has been found to be especially effectual. 
That this medicine operates by a tonic power, I have 
endeavoured to prove above, (214.) and from what is 
said in 215. the limitations to be observed in employing 
it may also be learned. When the gangrene arises from 
the violence of inflammation, the bark may not only 



* The separation between the dead and living parts, in cases of gangrene, 
is effected by ulcerative inflammation — in other words, it results from the ac- 
tion of the absorbents. Solid living matter is never melted down nor wasted 
away, either by a putrid, or any other kind of ferment. 



2?4 PRACTICE OF PHYSIC. 

fail of proving a remedy, but may do harm: and its 
power as a tonic is especially suited to those cases of 
gangrene which proceed from an original loss of tone, 
as in the case of palsy and oedema; or to those cases 
of inflammation where a loss of tone takes place, while 
the original inflammatory symptoms are removed. 

273. The other terminations of inflammation either 
do not admit of any treatment, except that of preventing 
them by the means of resolution ; or they belong to a trea- 
tise of surgery rather than to this place. 

Having thus, therefore, delivered the general doc- 
trine, I proceed now to consider the particular genera 
and species of inflammation. 

It has been hinted above (263.) that the difference 
of inflammation arises chiefly from the difference of the 
part affected: I have therefore arranged them as they 
are cutaneous, visceral, or articular; and in this 
order they are now to be considered. 



CHAPTER II. 
OF INFLAMMATION, MORE STRICTLY CUTANEOUS. 

274, CUTANEOUS inflammations are of two kinds, 
commonly distinguished by the names of phlegmon 
and erysipelas. 

Of the latter there are two cases, which ought to be 
distinguished by different appellations. When the disease 
is an affection of the skin alone, and very little of the 
whole system, or when the affection of the system is 
only symptomatical of the external inflammation, I shall 
give the disease the name of erythema: but when the 
external inflammation is an exanthema, and symptoma- 



PRACTICE OF PHYSIC. 225 

tical of an affection of the whole system, I shall then 
name the disease erysipelas. 

275. It is the erythema only that I am to consider here. 

For the distinction between Erythema and Phlegmon, 
I have formerly referred to the characters given of them 
in our Nosology. See Synops. Nosolog. Aieth. vol. ii. 
p. 5. gen. vii. spec. 1. and 2. But I think it proper 
now to deliver the characters of them more fully and 
exactly here, as follows. 

A Phlegmon is an inflammatory affection of the skin, 
with a swelling, rising generally to a more considerable 
eminence in the middle of it; of a bright red colour ; 
both the swelling and celour being pretty exactly cir- 
cumscribed; the whole being attended with a pain of 
distention, often of a stounding or throbbing kind, and 
frequently ending in suppuration. 

An Erythema, Rose, or St. Anthony's Fire, is an in- 
flammatory affection of the skin, with hardly any evi- 
dent swelling; of a mixed, and not very bright red co- 
lour, readily disappearing upon pressure, but quickly 
returning again; the redness of no regular circumscrip- 
tion, but spreading unequally, and continuing almost 
constantly to spread upon the neighbouring part; with 
a pain like to that from burning; producing blisters, 
sometimes of a small, sometimes of a larger size ; and 
always ending in a desquamation of the scarf-skin, 
sometimes in gangrene. 

This subject I am not to prosecute here, as properly 
belonging to surgery, the business of which I am seldom 
to enter upon in this work; and shall therefore observe 
only as necessary here, that the difference of these ap- 
pearances seems to depend upon the different seat of the 
inflammation. In the phlegmon the inflammation seems 
to affect especially the vessels on the internal surface of 
the skin communicating with the lax subjacent cellular 

vol. t. f f 



,22ti PRACTICE OF PHYSIC. 

texture; whence a more copious effusion, and that of 
serum convertible into pus, takes place. In the ery- 
thema, the inflammation seems to have its seat in the 
vessels on the external surface of the skin, communi- 
cating with the rete mucosum, which does not admit 
of any effusion, but what separates the cuticle, and gives 
occasion to the formation of a blister, while the smaller 
size of the vessels admits only the effusion of a thin 
fluid, very seldom convertible into pus. 

Besides these differences in the circumstances of these 
two kinds of inflammation, it is probable that they also 
differ with respect to their causes. Erythema is the effect 
of all kinds of acrids externally applied to the skin; and, 
when arising from an internal cause, it is from an acri- 
mony, poured out on the surface of the skin under the 
cuticle. In the phlegmon, an acrimony is not commonly 
evident* 

276. These differences in the seat and causes of the 
phlegmon and erythema being admitted, it will be evident 
that, when an erythema affects any internal part, it can 
take place in those only whose surfaces are covered with 
an epithelion, or membrane analogous to the cuticle. 

277. The same distinction between the seat and 
causes of the two diseases will, as I judge, readily explain 
what has been delivered by practical writers with respect 
to the cure of these different cutaneous inflammations. 
But I shall not, however, prosecute this here, for the 
reason given above, (275.) and, for the same reason, 
shall not say any thing of the variety of external inflam- 
mation that might otherwise be considered here. 

* The difference between Phlegmon and Erythema we believe to be, that 
the former originates in the skin, or cellular membrane, and is literally, 
therefore, a cutaneous disease ; while the latter has its origin in the stomach, 
and affects the skin secondarily by sympathy. Hence, erythema is neces- 
sarily the more serious disease. In Erythema the best topical application is 
a blister. Spirits of turpentine are said to be useful ; but we have never 
seen thenj applied. 



PRACTICE OF PHYSIC. 221 

CHAPTER lit. 
OF OPHTHALMIA, OR INFLAMMATION OF THE EYE. 

278. THE inflammation of the eye may be considered 
as of two kinds; according as it has its seat in the mem- 
branes of the ball of the eye, when I would name it 
ophthalmia membranarum; or as it has its seat in the 
sebaceous glands placed in the tarsus, or edges of the 
eyelids, in which case it may be termed ophthalmia 
tarsi. 

These two kinds are very frequently combined toge- 
ther, as the one may readily excite the other; but they 
are still to be distinguished according as the one or the 
other may happen to be the primary aifection, and pro- 
perly as they often arise from different causes. 

279. The inflammation of the membranes of the eye 
affects especially, and most frequently, the adnata, ap- 
pearing in a turgescence of its vessels; so that the red 
vessels which are naturally there, become not only in- 
creased in size, but there appear many more than did 
in a natural state. This turgescence of the vessels is 
attended with pain, especially upon the motion of the 
ball of the eye; and this, like every other irritation 
applied to the surface of the eye, produces an effusion 
of tears from the lachrymal gland. 

This inflammation commonly, and chiefly, affects the 
adnata spread on the anterior part of the bulb of the eye; 
but usually spreads also along the continuation of that 
membrane on the inside of the palpebrae; and, as that is 
extended on the tarsus palpebrarum, the excretories of 
the sebaceous glands opening there are also frequently 



22S PRACTICE OF PHYSIC. 

affected. When the affection of the adnata is consider- 
able, it is frequently communicated to the subjacent 
membranes of the eye, and even to the retina itself, 
which thereby acquires so great a sensibility, that the 
slightest impression of light becomes painful. 

280. The inflammation of the membranes of the eye 
is in different degrees, according as the adnata is more 
or less affected, or according as the inflammation is 
either of the adnata alone, or of the subjacent mem- 
branes also; and upon these differences, different spe- 
cies have been established, and different appellations 
given to them. But I shall not, however, prosecute 
the consideration of these, being of opinion, that all the 
cases of the Ophthalmia membranarum differ only in 
degree, and are to be cured by remedies of the same 
kind, more or less employed. 

The remote causes of Ophthalmia are many and va- 
rious; as, 

1. External violence, by blows, contusions, and 
wounds, applied to the eyes; and even very slight im- 
pulses applied, while the eyelids are open, to the ball 
of the eye itself, are sometimes sufficient for the pur- 
pose. 

2. Extraneous bodies introduced under the eyelids, 
either of an acrid quality, as smoke and other acrid va- 
pours, or of a bulk sufficient to impede the free motion 
of the eyelids upon the surface of the eyeball. 

3. The application of strong light, or even of a mo- 
derate light long continued. 

4. The application of much heat, and particularly of 
that with moisture. 

5. Much exercise of the eyes in viewing minute ob- 
jects. 

6. Frequent intoxication. 



PRACTICE OF PHYSIC. 229 

7. Irritation from other and various diseases of the 
eyes. 

8. An acrimony prevailing in the mass of blood, and 
deposited in the sebaceous glands on the edges of the 
eyelids. 

9. A change in the distribution of the blood, whereby 
either a more than usual quantity of blood, and with 
more than usual force, is impelled into the vessels of the 
head, or whereby the free return of the venous blood 
from the vessels of the head is interrupted. 

10. A certain consent of the eyes with the other 
parts of the system, whereby from a certain state d" 
these parts, either a simultaneous or an alternating af- 
fection of the eyes is produced. 

281. The proximate cause of Ophthalmia, is not dif- 
ferent from that of inflammation in general; and the dif- 
ferent circumstances of Ophthalmia may be explained 
by the difference of its remote causes, and by the dif- 
ferent parts of the eye which it happens to affect. This 
may be understood from what has been already said; 
and I shall now, therefore, proceed to consider the 

CURE. 

282. In the cure of Ophthalmia, the first attention 
will be always due to the removing of the remote causes, 
and the various means necessary for this purpose will 
be directed by the consideration of these causes enu- 
merated above. 

The Ophthalmia membranarum requires the reme- 
dies proper for inflammation in general; and when the 
deeper seated membranes are affected, and especially 
when a pyrexia is present, large general bleedings may 
be necessary. But this is seldom the case, as the Oph- 
thalmia, for the most part, is an affection purely local, 
accompanied with little or no pyrexia. General bleed- 
ings, therefore, from the arm or foot, have little effect 



230 PRACTICE OF PHYSIC. 

upon it; and the cure is chiefly to be obtained by topi- 
cal bleedings, that is, blood drawn from the vessels near 
the inflamed part; and opening the jugular vein or the 
temporal artery, may be considered as in some measure 
of this kind. Ft is commonly sufficient to apply a num- 
ber of leeches around the eye; and it is perhaps better 
still to draw blood from the temples by cupping and 
scarifying. In many cases, a very effectual remedy is, 
that of scarifying the internal surface of the inferior 
eyelid ; and more so still, is cutting the turgid vessels 
upon the adnata itself.* 

283. Besides blood-letting, purging, as a remedy 
suited to inflammation in general, has been considered 
as peculiarly adapted to inflammations in any of the 
parts of the head, and therefore to Ophthalmia; and it 
is sometimes useful; but, for the reasons given before 
with respect to general bleeding, purging in the case of 
Ophthalmia does not prove useful in any degree in 
proportion to the evacuation excited. 

284. For relaxing the spasm in the part, and taking 

* In one sentiment which our author advances in this paragraph we can- 
not altogether concur. We have seen several, we think many, cases of 
Opthalmia purely local — wherein, at least, no marks of general febrile ac- 
tion were manifested — in which topical evacuations by cups and leeches 
being altogether insufficient for the purposes of a cure, general blood-let- 
ting was copiously and very advantageously employed. In these instances it 
was necessary to enforce the antiphlogistic regimen with the utmost strict- 
ness, and to carry it to a greal extent. The entire exclusion of light 
and the prevention of all conversation are alike essential to successful prac- 
tice. 

In cases where fever does prevail, there are none of the phlegmasia; that 
require more copious evacuations, or a more vigorous treatment than oph- 
thalmia. Until the disease be completely cured relapses are very easily pro- 
duced All indulgences, therefore, and every exposure should be strictly 
prohibited. 

The repeated division of the turgid vessels of the adnata is a remedy use- 
ful, perhaps, in all cases; but indispensable where opake spots appear on 
the cornea. There exists, we believe, no other method whereby such 
spots can be so completely removed ; that which is here recommended de- 
stroying the channels that convey to them their nourishment. 



PRACTICE OF PHYSIC. 231 

off the determination of the fluids to it, blistering near 
the part has commonly been found useful. 

285. Electrical sparks taken from the eye will often 
suddenly discuss the inflammation of the adnata; but 
the effect is seldom permanent, and even a frequent re- 
petition seldom gives an entire cure. 

286. Ophthalmia, as an external inflammation, ad- 
mits of topical applications. All those, however, that 
increase the heat and relax the vessels of the part, prove 
commonly hurtful; and the admission of cool air to the 
eye, the proper application of cold water immediately to 
the ball of the eye, and the application of various cooling 
and astringent medicines, which at the same time do not 
produce much irritation, prove generally useful: even 
spirituous liquors, employed in moderate quantity, have 
often been of service.* 

287. In the cure of Ophthalmia much care is requi- 
site to avoid all irritation, particularly that of light; 
and the only safe and certain means of doing this is by 
confining the patient to a very dark chamber. 

288. These are the remedies of the Ophthalmia mem- 
branarum; and in the Ophthalmia tarsi, so far as it is 
produced by Ophthalmia membranarum, the same re- 
medies may be necessary. As, however, the Ophthal- 
mia tarsi may often depend upon an acrimony deposited 
in the sebaceous glands of the part, so it may require 
various internal remedies according to the nature of the 
acrimony in fault ; for which I must refer to the con- 

* When the eye is highly infamed, cold applications to it are injurious. 
They should never be employed, therefore, until, by other remedies, the 
inflammation is considerably reduced. Under the erroneous belief that 
cold is a sedative, we are persuaded that its premature application in the 
treatment of Ophthalmia has done much mischief. So has the too early use 
of solutions of saccharum saturni, white vitriol, and other astringent lotions. 
When inflammation is violent, such remedies are inadmissible. An excel- 
lent application to an inflamed eye is, the fine mucus produced by infus- 
ing the pith of sassafras in water. 



232 PRACTICE OF PHYSIC. 

sideration of scrofula, syphilis, or other diseases with 
which this Ophthalmia may be connected; and when 
the nature of the acrimony is not ascertained, certain 
remedies, more generally adapted to the evacuation of 
acrimony, such, for instance, as mercury, may be em- 
ployed.* 

289. In the Ophthalmia tarsi, it almost constantly 
happens that some ulcerations are formed on the tarsus. 
These require the application of mercury or copper, 
either of which may by itself sometimes entirely cure 
the affection; and these may even be useful when the 
disease depends upon a fault of the whole system. 

290. Both in the Ophthalmia membranarum, and in 
the Ophthalmia tarsi, it is necessary to obviate that glu- 
ing or sticking together of the eyelids which commonly 
happens in sleep; and this may be done by insinuating 
a little of any mild unctuous medicine, of some tena- 
city, between the eyelids before the patient shall go to 
sleep. 



CHAPTER IV. 
OF PHRENSY, OR PHRENITIS. 

291. THIS disease is an inflammation of the parts con- 
tained in the cavity of the cranium; and may affect 
either the membranes of the brain, or the substance of 
the brain itself. Nosologists have apprehended, that 
these two cases might be distinguished by different 

* In this description of Ophthalmia, we have often, with great relief and 
permanent advantage to our patients, prescribed the use of the ungnentum 
citrinum. The unguentum tutiae, and the unguentum cerussae acetatx are 
also serviceable. For the proper time of using them, the practitioner must 
rely onhis own judgment. 

In chronic Ophthalmia, laudanum in water, or a mixture of a watery solu- 
tion of opium, and an infusion of Spanish galls, is a very useful remedy. 



PRACTICE OF. PHYSIC. 233 

symptoms, and therefore by different appellations: but 
this does not seem to be confirmed by observation and 
dissection; and therefore I shall treat of both cases 
under the title of Phrensy, or Phrenitis. 

292. An idiopathic phrensy is a rare occurrence, a 
sympathetic more frequent; and the ascertaining either 
the one or the other is, upon many occasions, difficult. 
Many of the symptoms by which the disease is most 
commonly judged to be present, have appeared, when, 
from certain considerations, it was presumed, and even 
from dissection it appeared, that there had been no in- 
ternal inflammation; and on the other hand, dissections 
have shown, that the brain had been inflamed, when few 
of the peculiar symptoms of phrensy had before ap- 
peared* 

293. The symptoms by which this disease may be 
most certainly known, are a vehement pyrexia, or a vio- 
lent deep-seated headach, a redness and turgescence of 
the face and eyes, an impatience of light and noise, a 
constant watching, and a delirium impetuous and furi- 
ous. Some nosologists have thought these symptoms 
peculiar to an inflammation of the membranes, and that 
the inflammation of the substance of the brain was to be 
distinguished by some degree of coma attending it. It 
was for this reason that in the Nosology I added the 
Typhomania to the character of Phrenitis; but upon 

* Unless where it arises from mechanical violence, we believe that cere- 
bral inflammation has always its original seat in the stomach — at least in 
some part of the alimentary canal. Hence the advantages of copious purging - . ' 
Where no mechanical violence has been offered, we do not perceive how the 
brain can be originally assailed. Besides, tracts of country wherein bilious 
fever prevails, are most remarkable for phrenitic affections. 

The coup de soleil, or stroke of the sun, is not an original affection of the 
brain. It is a form of gastric disease — i. e. bilious fever. The brain is too 
well guarded to be primarily affected by the rays of the sun. Those agents, 
subtle and penetrating as they are, can reach it only through the medium of 
sympathy. 

VOL. I. G g 



234 PRACTICE OF PHYSIC. 

further reflection, I find no proper foundation for this; 
and if we pass from the characters above delivered, 
there will be no means of fixing the variety that occurs. 

I am here, as in other analogous cases, of opinion, 
that the symptoms above mentioned of an acute inflam- 
mation, always mark inflammations of membranous 
parts; and that an inflammation of the parenchyma or 
substance of v iscera, exhibits, at least commonly, a more 
chronic affection. 

294. The remote causes of phrensy, are all those 
which directly stimulate the membranes or substance of 
the brain: and particularly all those which increase the 
impetus of the blood in the vessels of the brain. Among 
these the exposure of the naked head to the direct rays 
of a xery warm sun is a frequent cause. The passions 
of the mind, and certain poisons, are amongst the re- 
mote causes of phrensy; but in what manner they ope- 
rate is not well understood. 

295. The cure of phrensy is the same with that of 
inflammation in general; but in phrensy the most pow- 
erful remedies are to be immediately employed. Large 
and repeated blood-letting is especially necessary; and 
the blood should be drawn from vessels as near as possi- 
ble to the part affected. The opening of the temporal 
artery has been recommended, and with some reason; 
but the practice is attended with inconvenience; and I 
apprehend that opening the jugular veins may prove 
more effectual; but at the same time, it will be gene- 
rally proper to draw blood from the temples by cupping 
and scarifying. 

296. It is probable, that purging, as it may operate 
by revulsion, may be of more use in this than in some 
other inflammatory affections. 

For the same purpose of revulsion, warm pediluvia 
are a remedy; but at the same time somewhat ambigu- 



PRACTICE OF PHYSIC. 235 

ous. The taking off the force of the blood in the ves- 
sels of the head by an erect posture, is generally use- 
ful.* 

297. Shaving of the head is always proper and ne- 
cessary for the admission of other remedies. Blister- 
ing is commonly useful in this disease, but chiefly when 
applied near the part affected.f 

298. Every part of the antiphlogistic regimen is here 
necessary, and particularly the admission of cold air. 
Even cold substances, applied close to the head, have 
been found safe and highly useful; and the application 
of such refrigerants as vinegar, is certainly proper. J 

299. It appears to me certain, that opiates are hurt- 
ful in every inflammatory state of the brain; and it is to 
be observed, that, from the' ambiguity mentioned in 
(292.) the accounts of practitioners, with regard to the 
juvantia and laedentia in this disease, are of very un- 
certain application. 



chapter v. 



OF THE QUINSY, OR CYNANCHE. 

300. THIS name is applied to every inflammation of 
the internal fauces; but these inflammations are differ- 
ent, according to the part of the fauces which may be 

* Profuse purging is highly useful in phrenilic affections. The most ac- 
tive and even drastic purges should be employed. 

f That they may produce their full effect, blisters should be permitted to 
remain on the head at least forty-eight hours, or even longer. 

t The most convenient and effectual method of applying cold to phr»*nitic 
patients, is to cover the head by bladders filled with pounded ice. When 
permanently applied, this proves a remedy of great effect 

Digitalis, in substance or tincture, taken until it has produced its peculiar 
effect on the pulse, is said to be highly useful in phrenitis. 



236 PRACTICE OF PHYSIC. 

affected, and according to the nature of the inflamma- 
tion. In the Nosology, therefore, after giving the cha- 
racter of the Cynanche as a genus, I have distinguish- 
ed five different species, which must here likewise be 
separately considered. 

Sect. I. — Of the Cynanche Tonsillaris. 

301. This is an inflammation of the mucous mem- 
brane of the fauces, affecting especially that congeries 
of mucous follicles which forms the tonsils, and spread- 
ing from thence along the velum and uvula, so as fre- 
quently to affect every part of the mucous membrane. 

302. The disease appears by some tumour, some- 
times considerable, and by a redness of the parts; is at- 
tended with a painful and difficult deglutition; with a 
pain sometimes shooting into the ear; with a trouble- 
some clamminess of the mouth and throat; with a fre- 
quent, but difficult, excretion of mucus; and the whole 
is accompanied with a pyrexia* 

303. This species of quinsy is never contagious. It 
terminates frequently by resolution, sometimes by sup- 
puration, but hardly ever by gangrene; although in this 
disease some sloughy spots, commonly supposed to be 
forerunners of gangrene, sometimes appear upon the 
fauces. 

304. This disease is commonly occasioned by cold 
externally applied, particularly about the neck. It af- 
fects especially the young and sanguine, and a disposi- 

* Some of the most excruciating affections of the ear we have ever wit- 
nessed have arisen from this complaint. A blister on the throat has rarely- 
failed to afford relief. 

We believe that the pain in the ear, from which many children suffer so 
much, is almost uniformly connected either with a carious tooth or an in- 
flammation of the tonsils. To these sources, therefore, practitioners will do 
well to direct their attention. 



PRACTICE OF PHYSIC. 037 

tion to it is often acquired by habit; so that from every 
considerable application of cold to any part of the body, 
this disease is readily induced. It occurs especially in 
spring and autumn, when vicissitudes of heat and cold 
frequently take place. The inflammation and tumour 
are commonly at first most considerable in one tonsil; 
and afterwards abating in that, increase in the other. 

305. In the cure of this inflammation, some bleed- 
ing may be proper: but large general bleedings will sel- 
dom be necessary. The opening of the ranular veins 
seems to be an insignificant remedy; and leeches set 
upon the external fauces are of more efficacy. 

306. At the beginning of the disease, full vomiting 
has been frequently found to be of great service. 

307. This inflammation may be often relieved by 
moderate astringents, and particularly by acids applied 
to the inflamed parts. In many cases, however, no- 
thing has been found to give more relief than the 
vapour of warm water received into the fauces by a 
proper apparatus.* 

308. The other remedies of this disease are rubefa- 
cient or blistering medicines, applied externally to the 
neck; and with these, the employment of antiphlogistic 
purgatives, as well as every part of the antiphlogistic 
regimen, excepting the application of cold. 

309. This disease, as we have said, often terminates 
by resolution, frequently accompanied with sweating; 



* Simple water, or sage tea, acidulated with vinegar artd sweetened with 
honey, makes an excellent gargarism in this disease. The addition of alum 
or nitre is thought to render the remedy more efficacious. 

Decoctions of oak bark, and solutions of carbonate of ammonia are also 
recommended; whatever increases the secretion from the part affected, by 
exciting action in the vessels, appears to be useful: for, here, as in other 
cases of topical infiammation, there exists a remora in the fluids, occasioned 
by a deficiency of vascular action. 



238 PRACTICE OF PHYSIC. 

which is therefore to be prudently favoured and en 
couraged.* 

310. When this disease shall have taken a tendency 
to suppuration, nothing will be more useful, than the 
frequent taking into the fauces the steams of warm 
water. When the abscess is attended with much swell- 
ing, if it break not spontaneously, it should be opened 
by a lancet: and this does not require much caution, as 
even the inflammatory state may be relieved by some 
scarification of the tonsils. 

I have never had occasion to see any case requiring 
bronchotomy.f 

Sect. II. — Of the Cynanche Maligna. 

311. This is a contagious disease, seldom sporadic, 
and commonly epidemic. It attacks persons of all ages, 
but more commonly those in a young and infant state. 
It attacks persons. of every constitution when exposed 
to the contagion, but most readily the weak and infirm. J 

* We have never perceived much advantage to be derived from sweating 
in this disease. In the treatment of topical inflammation, the discharge by 
the skin is a feeble remedy, and should never be suffered to stand in the 
way of such as are active. 

Bleeding, general!} and locally, purging, gargling and blistering are the 
remedies on which, in their treatment of this disease, practitioners of expe- 
rience principally rely. 

-j- In addition to the steams of warm water, which may be conveniently 
received from Mudge's or any other inhaler, warm poultices and fomenta- 
tions applied externally to the region of the fauces, are recommended as 
useful in promoting the suppuration of the tonsils. Nor ait- the) without 
their effect in relieving pain. Their employment, therefore, ought not to 
be neglected. 

\ From such observations as we have had an opportunity of making, we 
have no ground to consider cynanche maligna aa a contagious disease. Its 
attacking a number of persons at once, or in succession,in the same family or 
neighbourhood, affords no proof that it is so ; yet this is all the evidence 
that can be collected on the subject 

We believe it to be entirely an atmospheric complaint ; and that it pre- 
vails as an epidemic, because all persons hold intercourse with the atmo- 



PRACTICE OF PHYSIC. 239 

312. This disease is usually attended with a consider- 
able pyrexia; and the symptoms of the accession of this, 
such as frequent cold shiverings, sickness, anxiety, and 
vomiting, are often the first appearances of this disease. 
About the same time, a stiffness is felt in the neck, with 
some uneasiness in the internal fauces, and some hoarse- 
ness of the voice. The internal fauces, when viewed, 
appear of a deep red colour, with some tumour; but 
this last is seldom considerable, and deglutition is sel- 
dom difficult or painful. Very soon a number of white 
or ash-coloured spots appear upon the inflamed parts. 
These spots spread and unite, covering almost the whole 
fauces with thick sloughs; which falling off, discover 
ulcerations. While these symptoms proceed in the 
fauces, they are generally attended with a coryza which 
pours out a thin acrid and fetid matter, excoriafing the 
nostrils and lips. There is often also, especially in in- 
fants, a frequent purging: and a thin acrid matter flows 
from the an us,excoriating this and the neighbouring parts. 

313. With these symptoms, the pyrexia proceeds 
with a small, frequent, and irregular pulse; and there 
occurs a manifest exacerbation every evening, and 
some remission in the mornings. A great debility ap- 
pears in the animal functions; and the sensorium is 
affected with delirium, frequently with coma. 

314. On the second day, or sometimes later, efflores- 
cences appear upon the skin, which are sometimes in 
small points hardly eminent; but, for the most part, in 

sphere, the source through which its poison is diffused, and from which it is 
received into the human body. 

We are persuaded thai its original seat is in the stomach, and that the 
ulceration of the throat is but a secondary affection. Hence the importance 
of emetics, administered in the early stages of the disease 

Cuticular eruptions, accompanied with fever, proceed almost uniformly 
from a disordered stomach. Beside*, in the treatment of cynanche maligna, 
it is to the stomach alone that the principal and most important remedies are 
directed. Those applied to the throat are, at best, but palliative. 



240 PRACTICE OF PHYSIC 

patches of a red colour, spreading and uniting so as to 
cover the whole skin. They appear first about the face 
and neck, and in the course of some days spread by 
degrees to the lower extremities. The scarlet redness 
is often considerable on the hands and extremities of 
the fingers, which feel stiff and swelled. This eruption 
is often irregular, as to the time of its appearance, as to 
its steadiness, and as to the time of its duration. It 
usually continues four days, and goes off by some 
desquamation of the cuticle; but neither on its first ap- 
pearance, nor on its desquamation, does it always pro- 
duce a remission of the pyrexia, or of the other symp- 
toms. 

315. The progress of the disease depends on the state 
of the fauces and of the pyrexia. When the ulcers on 
the fauces, by their livid and black colour, by the fetor 
of the breath, and by many marks of acrimony in the 
fluids, show a tendency to gangrene, this takes place to 
a considerable degree; and the symptoms of a putrid 
fever constantly increasing, the patient dies, often on the 
third day, sometimes later, but for the most part before 
the seventh. The acrimony poured out from the diseased 
fauces must necessarily, in part, pass into the pharynx, 
and there spread the infection into the oesophagus, and 
sometimes through the whole of the alimentary canal, 
propagating the putrefaction, and often exhausting the 
patient by a frequent diarrhoea. 

The acrid matter poured out in the fauces being again 
absorbed, frequently occasions large swellings of the 
lymphatic glands about the neck, and sometimes to such 
a degree as to occasion suffocation. 

It is seldom that the organs of respiration escape 
entirely unhurt, and very often the inflammatory affection 
is communicated to them. From dissections it appears, 
that, in the Cynanche maligna, the larynx and trachea are 



PRACTICE OF PHYSIC. 241 

often affected in the same manner as in the Cynanche 
tracbealis; and it is probable, that, in consequence of 
that affection, the Cynanche maligna often proves fatal 
by such a sudden suffocation as happens in the proper 
Cynanche trachealis; but there is reason to suspect, 
that upon this subject dissectors have not always dis- 
tinguished properly between the two diseases.* 

316. These are the several fatal terminations of the 
Cynanche maligna; but they do not always take place. 
Sometimes the ulcers of the fauces are of a milder 
nature, and the fever is more moderate, as well as of a 
less putrid kind. And when, upon the appearance of 
the efflorescence on the skin, the fever suffers a remis- 
sion; when the efflorescence continues for three or four 
days, till it has spread over the whole body, and then 
ends by a desquamation, giving a further remission of 
the fever; this often entirely terminates, by gentle sweats, 
on or before the seventh day; and the rest of the dis- 
ease terminates in a few days more, by an excretion of 
sloughs from the fauces; while sleep, appetite, and the 
other marks of health return. 

From what is said in this and the preceding para- 
graph, the prognostics in this disease may be readily 
learned. 

317. In the cure of this disease, its septic tendency 
is chiefly to be kept in view. The debility, with which 



* This is a mistake. The progress of the disease corresponds with " the 
state of the fauces," but depends on that of the stomach, which regulates both 
the pyrexia and every other symptom appertaining to the complaint. 

Although the matter discharged from the ulcers in the throat must, if 
swallowed, necessarily tend to aggravate the disease, it is not to be regard- 
ed as the cause of the diarrhoea, which frequently marks its latter stages. 
That affection more properly arises from the injury done to the stomach 
and bowels, by the poison that originally produces the complaint. In the 
mean time, however, great care should be taken that the ulcerous matter 
from the throat do not find its way into the oesophagus. 

VOL. I. H h 



2&2 PRACTICE OF PHYSIC. 

it is attended, renders all evacuations by bleeding and 
purging improper, except in a few instances where the 
debility is less, and the inflammatory symptoms more 
considerable. The fauces are to be preserved from 
the effects of the acrid matter poured out upon them, 
and are therefore to be frequently washed out by anti- 
septic gargles or injections; and the septic tendency of 
the whole system should be guarded against and cor- 
rected by internal antiseptics, especially by the Peru- 
vian bark, given in substance, from the beginning, and 
continued through the course of the disease. Emetics, 
both by vomiting and nauseating, prove useful, espe- 
cially when employed early in the disease. When any 
considerable tumour occurs, blisters applied externally 
will be of service, and in any case may be fit to mode- 
rate the internal inflammation.* 



* For the treatment of this disease the indications are plain. They are, 
to keep clean the alimentary canal, to give strength and tone to the system, 
and to determine to the skin. The first of these is to be answered by eme- 
tics and purgatives, so far as they may be used with safety, and by gargles : 
the second, by bark, wine, the mineral acids, and other articles stimulating 
and cordial : and the third, by sudorifics and blisters. 

In addition to this, perfect cleanliness ought to be preserved, by frequently 
changing the bed and body clothes, ventilating the chamber, but not with 
cold or damp air, removing from it promptly all excrementitious matters, 
and diffusing occasionally through its atmosphere the fumes of vinegar, or 
portions of nitrous or muriatic acid gas. 

Children and young people being more frequently the subjects of this 
disease than adults, it is impracticable, for the most part, to induce them to 
swallow a sufficient quantity of the bark. In such cases, that remedy should 
be administered in the form of injection, suspended in mucilage of gum 
arabic, and united with laudanum, or a watery solution of opium, to prevent 
it from being discharged. 

It is scarcely necessary to observe, that to produce a given effect, the 
quantity of any medicine administered by injection, must be nearly fourfold 
that which would be administered by the mouth. 

Great care should be taken to keep in check, by opiates and astringents, 
the diarrhcen, which is apt to prove troublesome towards the close of this 
disease. 



PRACTICE OF PHYSIC. 243 



Sect. III. — Of Cynanche Trachealis. 

3 IS. This name has been given to an inflammation 
of the glottis, larynx, or upper part of the trachea, whe- 
ther it affect the membranes of these parts, or the mus- 
cles adjoining. It may arise first in these parts, and con- 
tinue to subsist in them alone; or it may come to affect 
these parts from the Cynanche tonsillaris or maligna 
spreading into them.* 

319. In either way it has been a rare occurrence, 
and few instances of it have been marked and recorded 
by physicians. It is to be known by a peculiar ringing 
sound of the voice, by difficult respiration, with a sense 
of straitening about the larynx, and by a pyrexia at- 
tending it. 

320. From the nature of these symptoms, and from 
the dissection of the bodies of persons who had died of 
this disease, there is no doubt of its being of an inflam- 
matory nature. It does not, however, always run the 
course of inflammatory affections, but frequently pro- 
duces such an obstruction of the passage of the air, 
as suffocates, and thereby proves suddenly fatal. 

321. If we judge rightly of the nature of this dis- 
ease, it will be obvious that the cure of it requires the 
most powerful remedies of inflammation to be employed 
upon the very first appearance of the symptoms. When 
a suffocation is threatened, whether any remedies can 



* We believe Cynanche Trachealis to be always an original disease, and 
never produced by any irregularities in Cynanche tonsillaris, or Cynanche ma- 
ligna. 

It is not, as our author alleges, a disease of " rare occurrence." In the 
United States, at least, it occurs very frequently. It is described by Dr. 
Boerhaave, in Aphorisms 801 and 802. Dr. Home, of Edinburgh, as Dr. 
Culle'n observes, was the first who gave us a correct idea of its nature. 



244 PRACTICE OF PHYSIC. 

be employed to prevent it, we have not had experience 
to determine. 

322. The accounts which books have hitherto given 
us of inflammations of the larynx, and the parts con- 
nected with it, amount to what we have now said; and 
the instances recorded have almost all of them happened 
in adult persons: but there is a peculiar affection of this 
kind happening especially to infants, which till lately 
has been little taken notice of. Dr. Home is the first 
who has given any distinct account of it; but, since he 
wrote, several other authors have taken notice of it, (see 
Michaelis De angina polyposa sive membranacea, Jlr- 
genlwati 1773) and have given different opinions with 
regard to it. Concerning this diversity of opinions I 
shall not at present inquire; but shall deliver the history 
and cure of this disease, in so far as these have arisen 
from my own observation, from that of Dr. Home, and 
of other skilful persons in this neighbourhood. 

323. This disease seldom attacks infants till after 
they have been weaned. After this period, the younger 
they are, the more they are liable to it. The frequency 
of it becomes less as children become more advanced; 
and there are no instances of children above twelve years 
of age being affected with it. It attacks children of the 
midland countries, as well as those who live near the 
sea. It does not appear to be contagious, and its attacks 
are frequently repeated in the same child. It is often 
manifestly the effect of cold applied to the body; and 
therefore appears most frequently in the winter and 
spring seasons. It very commonly comes on with the 
ordinary symptom of a catarrh; but sometimes the pe- 
culiar symptoms of the disease show themselves at the 
very first* 

* It may, perhaps, be true, that Cynanche trachealis is more incidental to 
children after they are weaned than before ; but it attacks them frequently 



PRACTICE OF PHYSIC. 245 

S24. These peculiar symptoms are the following: A 
hoarseness, with some shrillness and ringing sound, 
hoth in speaking and coughing, as if the noise came 
from a brazen tube. At the same time, there is a sense 
of pain about the larynx, some difficulty of respiration, 
wil'i a whizzing sound in inspiration, as if the passage 
of the air were straitened. The cough which attends it 
is commonly dry; and if any thing be spit up, it is a 
matter of a purulent appearance, and sometimes films 
resembling portions of a membrane. Together with 
these symptoms, there is a frequency of pulse, a rest- 
lessness, and an uueasy sense of heat. 

When the internal fauces are viewed, they are some- 
times without any appearance of inflammation: but fre- 
quently a redness and even swelling appear; and some- 
times in the fauces there is an appearance of matter 
like to that rejected by coughing. With the symptoms 
now described, and particularly with great difficulty of 
breathing, and a sense of strangling in the fauces, the 
patient is sometimes suddenly taken off. 

325. There have been many dissections made of in- 
fants who had died of this disease; and almost constantly 
there has appeared a preternatural membrane lining the 
whole internal surface of the upper part of the trachea, 

at every period, from the age of three months to that of six or seven years. 
At a later period we have rarely seen it. 

Although this disease often, perhaps always, when in a sporadic form, arises 
from improper exposure to cold or humidity, and is, therefore, connected 
with changes in the weather; it, notwithstanding, like other diseases, pre- 
vails, at times, as an epidemic, without any apparent dependence on the 
sensible qualities of the atmosphere. 

This appears to have been the case in the neighbourhood of Alexandria, 
in Virginia, in the year 1799, the period at which General Washington fell 
a victim to it ; and it was certainly the case in Philadelphia in the winter of 
of 1809-10, when the disease was productive of considerable mortality. On 
the latter occasion, we know, from observation, that the weather was regu- 
lar and pleasent for the season ; yet, for several weeks, the croup prevailed 
with the character of an epidemic; and we are informed on authority, which 
we cannot question, that the same thing is true in relation to the former. 



246 PRACTICE OF PHYSIC. 

and extending in the same manner downwards into 
some of its ramifications. This preternatural mem- 
brane may be easily separated, and sometimes has been 
found separated in part from the subjacent proper 
membrane of the trachea. This last is commonly 
found entire, that is, without any appearance of erosion 
or ulceration; but it frequently shows the vestiges of 
inflammation, and is covered by a matter resembling 
pus, like to that rejected by coughing; and ven often 
a matter of the same kind is found in the bronchiae, 
sometimes in considerable quantity.* 

326. From the remote causes of this disease; from 
the catarrhal symptoms commonly attending it; from 
the pyrexia constantly present with it; from the same 
kind of preternatural membrane being found in the 
trachea when the cynanche maligna is communicated 
to it; and, from the vestiges of inflammation on the tra- 
chea discovered upon dissection; we must conclude, 
that the disease consists in an inflammatory affection 
of the mucous membrane of the larynx and trachea, 
producing an exudation analogous to that found on the 



* In the dissections made in this country — and they have been numerous 
— this preternatural membrane in the trachea and bronchia: has rarely been 
found. In many, perhaps a majority of cases, but very little even of com- 
mon mucus, or of any thing else that marks inflammation, has been found in 
the neighbourhood of the seat of the disease. We have the high authority 
of our very able and distinguished friend, the present professor of the the- 
ory and practice of medicine in the university of Pennsylvania, to say, that 
such has been the result of his experience. Such has been, in like manner, 
the result of our own. Yet the disease is, for the most part, if not always, 
of an inflammatory character, and we are bound to believe, that the mem- 
brane does occasionally exist. 

We are persuaded that, in some of the worst cases, the local disease con- 
sists principally in a violent spasmodic affection of the muscles of the glottis 
and those in their neighbourhood. This spasm arises from the increased ir- 
ratability of these muscles, in consequence of the inflammation with which 
they are affected. In such instances, were mucus secreted into the trachea 
the complaint would be relieved, as occurs in catarrh, pneumonia, and other 
diseases of an inflammatory type. 



PRACTICE OF PHYSIC. 247 

surface of inflamed viscera, and appearing partly in 
a membranous crust, and partly in a fluid resembling 
pus. 

327. Though this disease manifestly consists in an 
inflammatory affection, it does not commonly end either 
in suppuration or gangrene. The peculiar and trouble- 
some circumstance of the disease seems to consist in a 
spasm of the muscles of the glottis, which, by inducing 
a suffocation, prevents the common consequences of 
inflammation. 

328. When this disease terminates in health, it is by 
a resolution of the inflammation, by a ceasing of the 
spasm of the glottis, by an expectoration of the matter 
exuding from the trachea, and of the crusts formed 
there; and frequently it ends without any expectoration, 
or at least with such only as attends an ordinary ca- 
tarrh. 

329. When the disease ends fatally, it is by a suffo- 
cation; seemingly, as we have said, depending upon a 
spasm affecting the glottis; but sometimes, probably, 
depending upon a quantity of matter filling the bron- 
chiae. 

330. As we suppose the disease to be an inflamma- 
tory affection, so we attempt the cure of it by the usual 
remedies of inflammation, and which for the most part 
I have found effectual. Bleeding, both general and 
topical, has often given immediate relief; and by being 
repeated, has entirely cured the disease. Blistering 
also, near to the part affected, has been found useful. 
Upon the first attack of the disease, vomiting immedi- 
ately after bleeding, seems to be of considerable use, 
and sometimes suddenly removes the disease. In every 
stage of the disease, the antiphlogistic regimen is ne- 
cessary, and particularly the frequent use of laxa- 
tive glysters. Though we suppose that a spasm af- 



248 PRACTICE OF PHYSIC. 

fecting the glottis is often fatal in this disease, I have not 
found antispasmodic medicines to be of any use.* 

Sect. IV. — Of Cynanche Pharyngcea. 

331. In the Cynanche tonsillaris, the inflammation 
of the mucous membrane often spreads upon the pha- 
rynx, and into the beginning of the oesophagus, and 
thereby renders deglutition more difficult and uneasy; 
but such a case does not require to be distinguished as 
a different species from the common Cynanche tonsil- 
laris; and only requires that blood-letting, and other re- 
medies, should be employed with greater diligence 
than in ordinary cases. We have never seen any case 
in which the inflammatiou began in the pharynx, or in 
which this part alone was inflamed; but practical wri- 
ters have taken notice of such a case; and to them, 
therefore, I must refer, both for the appearances which 
distinguish it, and for the method of cure. 



* The remedies for this disease are blood-letting, carried sometimes to * 
very considerable extent, severe and repeated vomiting - , purging - and blis- 
tering. Although these are all proper and necessary, vomiting we con- 
sider as the most important ; and tartarized antimony the most suitable arti- 
cle by which it can be produced. Besides diminishing arterial action, and 
thereby weakening the existing spasm, it determines to the skin, and dis- 
charges such troublesome and offending mucus as may be collected in the 
trachea. To excite puking in this disease, Cox's Hive Syrup (for which 
see his Dispensatory) is an efficacious remedy. Tincture of Digitalis given 
so as to produce sickness and nausea, is recommended as useful. W T e have 
never witnessed its effects. 

We usually exhibit in this disease, and, as we think, with great advantage, 
tartarized antimony combined with calomel, that the stomach, skin and bow- 
els, the three principal seats of excitement and sympathy, may be acted on 
at once. Of antimony given in nauseating doses, we have never witnessed 
the good effects. 

In protracted cases, where debility is great, and vomiting, therefore, in- 
admissible, we have administered, with success, a strong decoction of the 
Seneca root. 

Blisters applied to the throat should be kept open during the continuance 
•f the disease. When managed in this way they are useful. 



PRACTICE OF PHYSIC. 249 



Sect. V. — Of the Cynanche Parotidcea. 

332. This is a disease known to the vulgar, and 
among them has got a peculiar appellation, in almost 
every country in Europe; but has been little taken no- 
tice of by medical writers. It is often epidemic, and 
manifestly contagious. It comes on with the usual 
symptoms of pyrexia, which is soon after attended with 
a considerable tumour of the external fauces and neck. 
This tumour appears first as a glandular moveable tu- 
mour at the corner of the lower jaw; but the swelling 
soon becomes uniformly diffused over a great part of 
the neck; sometimes on one side only; but more com- 
monly on both. The swelling ccntinues to increase 
till the fourth day; but from that period it declines, and 
in a few days more passes off entirely. As the swell- 
ing of the fauces recedes, some tumour affects the tes- 
ticles in the male sex, or the breasts in the female. 
These tumours are sometimes large, hard, and some- 
what painful; but in this climate are seldom either very 
painful or of long continuance. The pyrexia attend- 
ing this disease is commonly slight, and recedes with 
the swelling of the fauces; but sometimes, when the 
swelling of the testicles does not succeed to that of the 
fauces, or when the one or the other has been suddenly 
repressed, the pyrexia becomes more considerable, is 
often attended with delirium, and has sometimes proved 
fatal* 

* In relation to Cynanche Parotidxa we have only to observe, that we 
consider it an atmospheric and epidemic, rather than a contagious disease. 
Like other epidemics, it pervades families, towns, and tracts of country ; but 
we have nothing to convince us that it passes by contagion from the sick to 
the well. We have seen but few cases of it that actually required medical 
aid. In these few, the remedies we have employed have been such as are 
usual in inflammatory complaints— blood-letting and purging, and occa- 
VOL. I. T i 



250 PRACTICE OF PHYSIC. 

333. As this disease commonly runs its course with- 
out either dangerous or troublesome symptoms, so it 
hardly requires any remedies. An antiphlogistic regi- 
men and avoiding cold, are all that will be commonly 
necessary. But when, upon the receding of the swell- 
ings of the testicles in males, or of the breasts in fe- 
males, the pyrexia comes to be considerable, and 
threatens an affection of the brain, it will be proper, 
by warm fomentations, to bring back the swelling; and 
by vomiting, bleeding, or blistering, to obviate the con- 
sequences of its absence. 



CHAPTER VI. 

OF PNEUMONIA, OR PNEUMONIC INFLAMMATION. 

334. UNDER this title I mean to comprehend the 
whole of the inflammations affecting either the viscera 
of the thorax, or the membrane lining the interior sur- 
face of that cavity: for neither do our diagnostics serve 
to ascertain exactly the seat of the disease; nor does 
the difference in the seat of the disease exhibit any 
considerable variation in the state of the symptoms, nor 
lead to any difference in the method of cure. 

335. Pneumonic inflammation, however various in its 
seat, seems to me to be always known and distinguish- 
ed by the following symptoms: pyrexia, difficult breath- 
ing, cough, and pain in some parts of thy thorax. But 

sional puking and blistering, with the rigid enforcement of an antiphlogistic 
regimen. 

We have never witnessed an instance of mortality from this disease ; nor 
have we seen many cases wherein was experienced any serious inconveni- 
ence by a translation of the inflammation to the testicles in males, or the 
breasts in females. As often as this accident has occurred in our practice, 
it has been in the persons of adults. It calls for a strict observance of the 
antiphlogistic regimen ; and generally yields to that without difficulty. 



PRACTICE OF PHYSIC. 25\ 

these symptoms are, on different occasions, variously 
modified. 

336. The disease almost always comes on with a cold 
stage, and is accompanied with the other symptoms of 
pyrexia; though, in a few instances, the pulse may not 
be more frequent, nor the heat of the body increased 
beyond what is natural. Sometimes the pyrexia is from 
the beginning accompanied with the other symptoms; 
but frequently it is formed for some hours before the 
other symptoms become considerable, and particularly 
before the pain be felt. For the most part, the pulse is 
frequent, full, strong, hard, and quick; but in a few in- 
stances, especially in the advanced state of the disease, 
the pulse is weak and soft, and at the same time irre- 
gular.* 

337. The difficulty of breathing is always present, 
and most considerable in inspiration; both because the 
lungs do not easily admit of a full dilatation, and be- 
cause the dilatation aggravates the pain attending the 
disease. The difficulty of breathing is also greater, when 
the patient is in one posture of his body rather than 
another. It is generally greater when he lies upon the 
side affected; but sometimes the contrary happens. 
Very often the patient cannot lie easy upon either side, 
finding ease only when lying on his back; and some- 
times he cannot breathe easily, except when in some- 
what of an erect posture.f 

* In a great majority of cases the pain is felt before the pyrexia, but is 
seldom very severe until the pyrexia occurs. 

A pulse is frequent, when the strokes are numerous in a given time ; 
quick, when each stroke is performed in a very short time. In the phrase 
*' a quick and frequent pulse," therefore, there is no tautology. 

f The reason of this alternate increase and diminution of difficulty in 
breathing is obvious. In inspiration the inflamed membrane or part is dis- 
tended, but in expiration relaxed : and, we well know that, whether in the 
thorax or elsewhere, distention is laborious and painful, and relaxation com- 
paratively easy and grateful, to every part where inflammation prevail!. 



252 PHACTIQE OL> PHYSIC. 

338. A cough always attends this disease; but in dif- 
ferent cases, is more or less urgent and painful. It is 
sometimes dry, that is, without any expectoration, espe- 
cially in the beginning of the disease; but more com- 
monly it is, even from the first, moist, and the matter 
spit up various both in consistence and colour; and fre- 
quently it is streaked with blood.* 

339. The pain attending this disease, is, in different 
cases, felt in different parts of the thorax, but most fre- 
quently in one side. It has been said to affect the right 
side more frequently than the left; but this is not certain ; 
while on the other hand, it is certain that the left side 
has been very often affeqted. The pain is felt sometimes 
as if it were under the sternum; sometimes in the back 
between the shoulders; and when in the sides, its place 
has been higher or lower, more forward or backward: 
but the place of all others most frequently affected, is 
about the sixth or seventh rib, near the middle of its 
length, or a little more forward. The pain is often se- 
vere and pungent; but sometimes more dull and obtuse, 
with a sense of weight rather than of pain. It is most 
especially severe and pungent when occupying the place 
last mentioned. For the most part it continues fixed 
in one place; but sometimes shoots from the side to the 
scapula on one hand, or to the sternum and clavicle on 
the other. 

340. The varying state of symptoms now mentioned, 
does not always ascertain precisely the seat of the dis- 
ease. To me it seems probable, that the disease is al- 
ways seated, or at least begins, in some parts of the 
pleura; taking that membrane in its greatest extent, as 

* In cases where the mucus discharged from the lungs is mixed with 
blood, the practitioner cannot be too prompt in emptying the blood-vessels, 
by means of venesection, as far as the other circumstances of the disease and 
the state of the system will admit For a rupture of even the smallest 
blood-vessel, in the lungs, ought to be suffered to heal as speedily and com- 
pletely as possible. 



PRACTICE OF PHYSIC. 253 

now commonly understood; that is, as covering not only 
the internal surface of the cavity of the thorax, but also 
as forming the mediastinum, and as extended over the 
pericardium, and over the whole surface of the lungs. 

341. There is, therefore little foundation for distin- 
guishing this disease by different appellations taken from 
the part which may be supposed to be chiefly affected. 
The term Pleurisy, might with propriety be applied to 
every case of the disease; and has been very improperly 
limited to that inflammation which begins in, and chiefly 
affects the pleura costatis. I have no doubt that such 
a case does truly occur; but, at the same time, I appre- 
hend it to be a rare occurrence; and that the disease 
much more frequently begins in, and chiefly affects, the 
pleura investing the lungs, producing all the symptoms 
supposed to belong to what has been called the Pleuri- 
tis vera. 

342. Some physicians have imagined that there is a 
case of pneumonic inflammation particularly entitled to 
the appellation of Peripneumony ; and that is, the case 
of an inflammation beginning in the parenchyma or 
cellular texture of the lungs, and having its seat chiefly 
there. But it seems to be very doubtful, if any acute 
inflammation of the lungs, or any disease which has been 
called Peripneumony, be of that kind. It seems proba- 
ble, that every acute inflammation begins in membran- 
ous parts; and in every dissection of persons dead of 
peripneumony, the external membrane of the lungs, or 
some part of the pleura, has appeared to have been con- 
siderably affected. 

343. An inflammation of the pleura covering the up- 
per surface of the. diaphragm, has been distinguished by 
the appellation of Parapkrcnitis, as supposed to be at- 
tended with the peculiar symptoms of delirium, risus 
sardonicus, and other convulsive motions: but it is cer- 



251 PRACTICE OF PHYSIC. 

tain, that an inflammation of that portion of the pleura, 
and affecting also even the muscular substance of the 
diaphragm, has often taken place without any of these 
symptoms; and I have not met with either dissections, 
which support the opinion, that an inflammation of the 
pleura covering the diaphragm, is attended with de- 
lirium more commonly than any other pneumonic in- 
flammation.* 

344. With respect to the seat of pneumonic inflam- 
mation, I must observe further, 4hat although it may 
arise and subsist chiefly in one part of the pleura only, 
it is however frequently communicated to other parts 
of the same, and commonly communicates a morbid 
affection through its whole extent. 

345. The remote cause of pneumonic inflammation, 
is commonly cold applied to the body, obstructing per- 
spiration, and determining to the lungs; while at the 
same time the lungs themselves are exposed to the ac- 
tion of cold. These circumstances operate especially, 
when an inflammatory diathesis prevails in the system; 
and, consequently, upon persons of the greatest vigour; 
in cold climates; in the winter season; and particularly 
in the spring, when vicissitudes of heat and cold are 
frequent. The disease, however, may arise in any sea- 
son when such vicissitudes occur. 

Other remote causes also may have a share in this 
matter; such as every means of obstructing, straining, 
or otherwise injuring the pneumonic organs. 

Pneumonic inflammation may happen to persons in 
any age, but rarely to those under the age of puberty: 

* The proximity of the diaphragm to the stomach, and the probability of 
its disordering that viscus, is the only reason, we apprehend, why ; an inflam- 
mation of it should have any influence in the production of delirium. Be- 
tween the diaphragm and the brain directly, we do not believe that much 
sympathy subsists : but, between the stomach and the brain, the sympathy 
is not only direct but powerful. 



PRACTICE OF PHYSIC. 255 

and most commonly it affects persons somewhat ad- 
vanced in life, as those between forty-five and sixty 
years ; those too, especially of a robust and full habit. 

The pneumonic inflammation has been sometimes so 
much an epidemic, as to occasion a suspicion of its de- 
pending upon a specific contagion; but I have not met 
with any evidence in proof of this.— See Morgagni 
de causis et sedibus morborum, epist. xx. art. 26* 



* Cold and humidity applied to the body act as the remote exciting cause 
of peripneumony. But, inasmuch as this disease sometimes prevails as an 
epidemic, it must have also a remote predisposing cause. This we must look 
for in the insensible qualities of the atmosphere ; not in any vicissitudes of 
its temperature or humidity. It is to be found in a peculiar atmospheric 
constitution, creating an unusual liability to pneumonic inflammation. 

Of the occasional existence of such a constitution we have abundant evi- 
dence : and it is it, not contagiom that spreads peripneumony through fami- 
■lies and neighbourhoods. During its prevalence, vicissitudes in the wea- 
ther, and other causes, which, in common times, would do no mischief, excite 
the disease in numerous instances. Such a constitution, in whatever it may 
consist, is to peripneumony, what an atmosphere replete with marsh mias- 
mata is to intermitting fever : it creates a predisposition to it, leaving nothing 
necessary but an exciting cause to call it into action. Under the former 
constitution, the same cause gives rise to a peripneumony, which, under the 
latter, excites an intermittent. 

To others of the phlegmasia: similar remarks may be applied. They too 
prevail as epidemics, and, under such circumstances, depend on a peculiar 
predisposing constitution of the atmosphere. By this constitution the seed 
is sown in a suitable soil, and nothing is wanting but the necessary excite- 
ment to awaken it into life. 

Such is the case With influenza, scarlatina, hooping cough, and several 
other complaints. 

The doctrine of atmospheric constitutions is curious and interesting; and 
has never yet been thoroughly investigated. It constitutes the philosophy of 
epidemics, without which the principles of their propagation, and the laws 
that govern them, can never be well understood. 

To every epidemic, the constitution producing it stands related, as the 
autumnal atmosphere of a marshy country docs to the various forms of bili- 
ous fever ; as one of the essential conditions of its existence. 

Peripneumony, when epidemic, is more malignant and dangerous than 
when only sporadic. The reason is obvious. In the latter case it is brought 
into existence by a tingle came,- in the former, by the combined and more 
powerful operation of two. Besides, in every epidemic peripneumony we 
have witnessed, the topical affection, instead of being strictly confined to 
the thorax, has extended to some of the abdominal viscera ; more especially 



25Q PRACTICE OF PHYSIC. 

346. The pneumonic, like other inflammations, may 
terminate by resolution, suppuration, or gangrene ; but 
it has also a termination peculiar to itself, as has been 
hinted above (259.) ; and that is, when it is attended with 
an effusion of blood into the cellular texture of the 
lungs, which soon interrupting the circulation of the 
blood through this viscus, produces a fatal suffocation. 
This, indeed, seems to be the most common termina- 
tion of pneumonic inflammation, when it ends fatally; 
for, upon the dissection of almost every person dead 
of the disease, it has appeared that such an effusion had 
happened.* 

347. From these dissections also we learn, that pneu- 
monic inflammation commonly produces an exudation 
from the internal surface of the pleura, which appears 
partly as a soft viscid crust, often of a compact, mem- 
branous form, covering every where the surface of the 
pleura, and particularly those parts where the lungs ad- 
here to the pleura costalis, or mediastinum; and this 
crust seems always to be the cement of such adhesions. 
The same exudation shows itself also by a quantity 
of a serous whitish fluid commonly found in the cavity 
of the thorax; and some exudation or effusion is usually 



•.he stomach and liver. Hence it oftentimes receives the denomination of 
lilious pleurisy. But it is well known, that, as a general rule, abdominal in- 
flammations are much more malignant and dangerous, than those that affect 
only the viscera of the thorax. 

Among the exciting causes of peripneumony may be enumerated, violent 
exertions in speaking, singing, playing on wind instruments of music, or any 
.kind of exertion that gives inordinate action to the lungs. To these may be 
added, the breathing of air adulterated by an admixture of deleterious va- 
pours; such as the fumes of arsenic, of sulphur, or of the muriatic acid. Let 
chemists, therefore, in their experiments, and artists in their daily employ. 
nients, beware of inhaling these aerial poisons. 

* Dropsical effusion, in the form of hydrothorax or hydrops pericardii, 
constitutes another mode in which pneumonic inflammation is known to ter 
minate. 



PRACTICE OF PHYSIC. 251 

found to have been made likewise into the cavity of the 
pericardium.* 

348. It seems probable, too that a like effusion is 
sometimes made into the cavity of the bronchiae: for, 
in some persons who have died after labouring under a 
pneumonic inflammation for a few days only, the bron- 
chiae have been found filled with a considerable quan- 
tity of a serous and thickish fluid; which, I think, must 
be considered rather as the effusion mentioned, having 
had its thinnest part taken off by respiration, than as a 
pus so suddenly formed in the inflamed part. 

349. It is, however, not improbable that this effusion, 
as well as that made into the cavities of the thorax and 
pericardium, may be a matter of the same kind with that 
which, in other inflammations is poured into the cellu- 
lar texture of the parts inflamed, and there converted 
into pus; but, in the thorax and pericardium, it does not 
always assume that appearance, because the crust co- 
vering the surface, prevents the absorption of the thin- 
ner part. This absorption, however, may be compen- 
sated in the bronchia? by the drying power of the air; 
and therefore the effusion into them may put on a more 
purulent appearance. 

In many cases of pneumonic inflammation, when the 
sputa are very copious, it is difficult to suppose that the 
whole of them proceed from the mucous follicles of the 
bronchiae. It seems more probable that a great part of 
them may proceed from the effused serous fluid we have 
been mentioning, and this too will account for the sputa 
being so often of a purulent appearance. Perhaps the 
same thing may account for that purulent expectoration, 
as well as that purulent matter found in the bronchiae, 

• The appearances mentioned in this paragraph are nothing but those of 
adhesive inflammation — another mode in which pneumonic inflammation 
often terminates. 

VOL. Ii K k 



258 PRACTICE OF PHYSIC. 

which the learned Mr. de Haen says he had often ob- 
served, when there was no ulceration of the lungs: and 
this explanation is at least more probable than M. de 
Haen's supposition of a pus formed in the circulating 
blood.* 

350. To conclude this subject, it would appear, that 
the effusion into the bronchiae which we have mention- 
ed, often concurs with the effusion of red blood in occa- 
sioning the suffocation, which fatally terminates pneu- 
monic inflammation; that the effusion of serum alone 
may have this effect; and that the serum poured out in 
a certain quantity, rather than any debility in the powers 
of expectoration, is the cause of that ceasing of expec- 
toration which very constantly precedes the fatal event. 
For, in many cases, the expectoration has ceased, when 
no other symptoms of debility have appeared, and when, 
upon dissection, the bronchiae have been found full of 
liquid matter. Nay, it is even probable, that in some 
cases such an effusion may take place, without any 
symptoms of violent inflammation; and in other cases, 
the effusion taking place may seem to remove the symp- 
toms of inflammation which had appeared before, and 
thus account for those unexpected fatal terminations 
which have sometimes happened. Possibly this effu- 
sion may account also for many of the phenomena of 
the Peripneumonia Notha. 

351. Pneumonic inflammation seldom terminates by 
resolution, without being attended with some evident 
evacuation. An hsemorrhagy from the nose happening 
upon some of the first days of the disease, has some- 
times put an end to it; and it is said that an evacuation 

* Nothing: can be more replete with error, than our author's hypothesis 
of the formation of pus, as stated in this paragraph. Indeed, for a man of 
an observing, sound, and discriminating mind, most of his hypotheses are 
exceedingly wild. 



PRACTICE OF PHYSIC. 259 

from the hemorrhoidal veins, a bilious evacuation by 
stool, and an evacuation of urine with a copious sedi- 
ment, have severally had the same effect: but such oc- 
currences have been rare and unusual. 

The evacuation most frequently attending, and seem- 
ing to have the greatest effect in promoting resolution, 
is an expectoration of a thick, white, or yellowish mat- 
ter, a little streaked with blood, copious, and brought 
up without either much or violent coughing. 

Very frequently the resolution of this disease is at- 
tended with, and perhaps produced by a sweat, which 
is warm, fluid, copious over the whole body, and at- 
tended with an abatement of the frequency of the pulse, 
of th^ heat of the body, and of other febrile symptoms.* 

352. The prognostics in this disease are formed from 
observing the state of the principal symptoms. 

A violent pyrexia is always dangerous. 

The danger, however, is chiefly denoted by the diffi- 
culty of breathing. When the patient can lie on one 
side only; when he can lie on ueither side, but upon his 
back only; when he cannot breathe with tolerable ease, 
except the trunk of his body be erect; when, even in 
this posture the breathing is very difficult, and attended 
with a turgescence and flushing of the face, together 
with partial sweats about the head and neck, and an ir- 
regular pulse; these circumstances mark the difficulty 
of breathing in progressive degrees, and, consequently, 
in proportion, the danger of the disease. 



* Bilious evacuations by stool, and an evacuation of urine with a copious 
sediment, are concomitants, not causes of the resolution of pneumonic in- 
flammation. 

A secretion of mucus from the bronchi* shows, that the inflamed vessels, 
which had been in a paralytic or powerless state, are now beginning to act, 
and to relieve themselves of the superabundant portion of fluids which had 
oppressed them. 



260 PRACTICE OF PHYSIC. 

A frequent violent cough aggravating the pain is al- 
ways the symptom of an obstinate disease. 

As I apprehend that the disease is hardly ever resolved, 
without some expectoration : so a dry cough must be 
always an unfavourable symptom. 

As the expectoration formerly described, marks that 
the disease is proceeding to a resolution; so an expecto- 
ration which has not the conditions there mentioned, 
must denote at least a doubtful state of the disease; but 
the macks taken from the colour of the matter, are for 
the most part fallacious. 

An acute pain, very much interrupting inspiration, is 
always the mark of a violent disease; though not of one 
more dangerous, than an obtuse pain, attended with 
very difficult respiration. 

When the pains which at first had affected one side 
only, have afterwards spread into the other; or when 
leaving the side first affected, they entirely pass into the 
other; these are always marks of an increasing, and, 
therefore, of a dangerous disease. 

A delirium coming on during a pneumonic inflam- 
mation, is constantly a symptom denoting much danger.* 

353. When the termination of this disease proves fa- 
tal, it is on one or other of the days of the first week, 
from the third to the seventh. This is the most com- 
mon case; but in a few instances, death has happened 
at a later period of the disease. 

When the disease is violent, but admitting of resolu- 
tion, this also happens frequently in the course of the 



* In his prognosis generally, our author is correct, and well worthy of be- 
ing attentively studied. But we cannot agree with him, that, when pneu- 
monic pains, " leaving the side first affected, pass entirely into the other," 
this circumstance " marks a dangerous and increasing disease." 

We think we have generally found a shifting of pneumonic pains to fur- 
nish evidence of a manageable disease 



PRACTICE OF PHYSIC. 261 

first week; but, in a more moderate state of the disease, 
the resolution is often delayed to the second week. 

The disease, on some of the days, from the third to 
the seventh, generally suffers a remission: which, how- 
ever, may be often fallacious, as the disease does some- 
times return again with as much violence as before, and 
then with great danger. 

Sometimes the disease disappears on the second or 
third day, while an erysipelas makes its appearance on 
some external part: and if this continue fixed, the pneu- 
mouic inflammation does not recur. 

354. Pneumonia, like other inflammations, often 
ends in suppuration or gangrene.* 

355. When a pneumonia, with symptoms neither very 
violent nor very slight, have continued for many days, 
it is to be feared it will end in a suppuration. This, how- 
ever, is not to be determined precisely by the number 
of days ; for, not only after the fourth, but even after the 
tenth day, there have been examples of a pneumonia, 
ending by a resolution; and if the disease has suffered 
some intermission and again recurred, there may be 
instances of a resolution happening at a much later 
period from the beginning of the disease, than that just 
now mentioned.! 

356. But if a moderate disease, in spite of proper re- 
medies employed, be protracted to the fourteenth day 
without any considerable remission, a suppuration is 

* The pathognomonic symptoms of incipient gangrene, are, relief from 
pain, a purulent spitting streaked with deep coloured blood, or with a black- 
ish matter; a fetid breath ; a rattling in the throat ; a dejected and languid 
countenance; a dim eye; a feeble, quick, and frequent pulse; green, fetid 
stools; and urine of a bright flame colour, or depositing a blackish flaky se- 
diment. 

f When a physician is called in within twenty-four, or even thirty-six 
hours after the commencement o*" peripneumony, it is disgraceful to him 
if he suffers it to terminate in suppuration. By proper evacuations, such an 
event may be easily, and, we think we may add, with certainty, prevented. 



262 PRACTICE OF PHYSIC. 

pretty certainly to be expected; and it will be still more 
certain, if no signs of resolution have appeared, or if an 
expectoration which had appeared shall have again 
ceased, and the difficulty of breathing has continued or 
increased, while the other symptoms have rather abated. 

357. That in a pneumonia, the effusion is made, 
which may lay the foundation of a suppuration, we con- 
clude from the difficulty of breathing becoming greater 
when the patient is in a horizontal posture, or when he 
can lie more easily upon the affected side. 

358. That in such cases, a suppuration has actually 
begun, may be concluded from the patient's being fre- 
quently affected with slight cold shiverings, and with a 
sense of cold felt sometimes in one, and sometimes in 
another part of the body. We form the same conclusion 
also from the state of the pulse, which is commonly 
less frequent and softer, but sometimes quicker and 
fuller than before. 

359. That a suppuration is already formed, may be 
inferred from there being a considerable remission of 
the pain which had before subsisted, while along with 
this, the cough, and especially the dyspnoea, continue, 
and are rather augmented. At the same time, the fre- 
quency of the pulse, is rather increased; the feverish 
state suffers considerable exacerbations every evening, 
and by degrees, a hectic, in all its circumstances, comes 
to be formed. 

360. The termination of pneumonia by gangrene, is 
much more rare than has been imagined; and when it 
does occur, it is usually joined with the termination by 
effusion, (346.) and the symptoms of the one are hardly 
to be distinguished from those of the other. 

361. The cure of pneumonic inflammation, must pro- 
ceed upon the general plan, (264.) but the importance of 
the part affected, and the danger to which it is exposed. 



PRACTICE OF PHYSIC. 268 

require that the remedies be fully, as well as early em- 
ployed. 

362. The remedy chiefly to be depended upon, is 
that of bleeding at the arm; which will be performed 
with most advantage in the arm of the side most affect- 
ed, but may be done in either arm, as may be most 
convenient for the patient or the surgeon. The quantity 
drawn must be suited to the violence of the disease, and 
to the vigour of the patient; and generally ought to be 
as large as this last circumstance will allow. The re- 
mission of pain, and the relief of respiration, during the 
flowing of the blood, may limit the quantity to be then 
drawn; but if these symptoms of relief do not appear, 
the bleeding should be continued till the symptoms of a 
beginning syncope come on. It is seldom that one 
bleeding, however large, will prove a cure of this dis- 
ease ; and although the pain and difficulty of breathing 
may be much relieved by the first bleeding, these symp- 
toms commonly, and after no long interval, recur, often 
with as much violence as before. In the event of such 
recurrence, the bleeding is to be repeated, even in the 
course of the same day, and perhaps to the same quan- 
tity as before. 

Sometimes the second bleeding may be larger than 
the first. There are persons who, by their constitution, 
are ready to faint, even upon a small bleeding; and in 
such persons this may prevent the drawing so much 
blood at first as a pneumonic inflammation might re- 
quire; but, as the same persons are frequently found to 
bear after-bleedings better than the first, this allows the 
second and subsequent bleedings to be larger, and to 
such a quantity as the symptoms of the disease may 
seem to demand. 

363. It is according to the state of the symptoms, 
that bleedings are to be repeated; and they will be more 



264 PRACTICE OF PHYSIC. 

effectual when practised in the course of the first three 
days, than afterwards; but they are not to be omitted, 
although four days of the disease may have already 
elapsed. If the physician shall not have been called in 
sooner; or if the bleedings practised during the first 
days shall not have been large enough, or even although 
these bleedings shall have procured some remission; 
yet upon the recurrence of the urgent symptoms, the 
bleeding should be repeated at any period of the dis- 
ease, especially within the first fortnight; and even af- 
terwards, if a tendency to suppuration be not evident, 
or, if, after a seeming solution, the disease shall have 
again returned.* 

364. With respect to the quantity of blood which 
ought, or which with safety may be taken away, no ge- 
neral rules can be delivered, as it must be very differ- 
ent, according to the state of the disease and constitu- 
tion of the patient. 

In an adult male of tolerable strength, a pound of 
blood, avoirdupois, is a full bleeding. Any quantity 
above twenty ounces, is a large, and any quantity be- 
low twelve, a small bleeding. A quantity of from four 
to five pounds, in the course of two or three days, is ge- 
nerally as much as such patients will safely bear; but, if 
the intervals between the bleedings and the whole of 
the time during which the bleedings have been em- 



* As long as the pain, cough, difficulty of breathing, and hardness of the 
pulse remain, the physician may with safety continue to bleed, entirely re- 
gardless of the period of the disease. In his repetitions of venesection, he 
must be governed entirely by the effects produced. If circumstances call 
for it, three times in twenty-four hours are quite admissible. In some cases 
three pints of blood have been drawn in a day with evident advantage. Such 
instances, however, do not very frequently occur. 

To prevent syncope, let the patient lie in a horizontal posture ; or even 
with his head lower than his body. Fainting sometimes occurs on the first 
act of venesection, but at no subsequent repetition of it. 



PRACTICE OF PHYSIC. 265 

ployed have been long, the quantity taken upon the 
whole may be greater. 

S65. When a large quantity of blood has been al- 
ready taken from the arm, and when it is doubtful if 
more can with safety be drawn in that manner, some 
blood may still be taken by cupping and scarifying. 
Such a measure will be more particularly proper, when 
the continuance or recurrence of pain, rather than the 
difficulty of breathing, becomes the urgent symptom; 
and then the cupping and scarifying should be made as 
near to the pained part as can conveniently be done. 

366. An expectoration takes place sometimes very 
early in this disease; but if, notwithstanding that, the 
urgent symptoms should still continue, the expectora- 
tion must not supersede the bleedings mentioned; and 
during the first days of the disease, its solution is not to 
be trusted to the expectoration alone. It is in a more 
advauced stage only, when the proper remedies have 
been before employed, and when the symptoms have 
suffered a considerable remission, that the entire cure 
may be trusted to a copious and free expectoration.* 

367. During the first days of the disease, I have not 
found that bleeding stops expectoration. On the con- 
trary, I have often observed bleeding promote it; and it 
is in a more advanced stage of the disease only, when 
the patient, by large evacuations and the continuance of 
the disease, has been already exhausted, that bleeding 
seems to stop expectoration. It appears to me, that 
even then bleeding does not stop expectoration, so much 
by weakening the powers of expectoration, as by fa- 
vouring the serous effusion into the bronchia?, (348) 
and thereby preventing it. 

* Our author's sentiments, as expressed in this and the next paragraph, 
respecting blood-letting and expectoration, are correct. The former does 
not injuriously check the latter, but often promotes it. 
VOL. I. j, J 



2Q6 PRACTICE OF PHYSIC. 

368. While the bleedings we have mentioned shall 
be employed, it will be necessary to employ also every 
part of the antiphlogistic regimen, (130 — 132) and par- 
ticularly to prevent the irritation which might arise 
from any increase of heat. For this purpose, it will be 
proper to keep the patient out of bed, while he can 
bear it easily ; and when he cannot, to cover him very 
lightly while he lies in bed. The temperature of his 
chamber ought not to exceed sixty degrees of Faren- 
heit's thermometer; and whether it may be at any time 
colder, I am uncertain.* 

369. Mild and diluent drinks, moderately tepid, at 
least never cold, given by small portions at a time, 
ought to be administered plentifully. These drinks 
may be impregnated with vegetable acids. They may 
be properly accompanied also with nitre, or some other 
neutrals; but these salts should be given separately from 
the drinks. 

It has been alleged, that both acids and nitre are 
ready to excite coughing, and in some persons they cer- 
tainly have this effect; but except in persons of a pecu- 
liar habit, I have not found their effects in exciting 
cough so considerable or troublesome as to prevent our 
seeking the advantages otherwise to be obtained from 
these medicines.f 

370. Some practitioners have doubted, if purgatives 
can be safely employed in this disease; and indeed a 
spontaneous diarrhoea occurring in the beginning of 
the disease has seldom proved useful: but I have found 
the moderate use of cooling laxatives generally safe, 

* The patient ought not to be "kept out of bed," but may be lightly co- 
vered in it. He should be kept where he will be most at his ease ; which 
is certainly in bed. 

f Barley water, flaxseed tea, bran tea, toast and water, or lemonade, are 
suitable drinks: so is a mixture of molasses or currant jelly in water. These 
may be taken, in general, ad libitum. 



PRACTICE OF PHYSIC. 267 

and have always found it useful to keep the belly open 
by frequent emollient glysters. 

371. To excite full vomiting by emetics, I judge to 
be a dangerous practice in this disease: but I have 
found it useful to exhibit nauseating doses; and in a 
somewhat advanced state of the disease, I have found 
such doses prove the best means of promoting expecto- 
ration.* 

372. Fomentations and poultices applied to the pain- 
ed part have been recommended, and may be useful; 
but the application of them is often inconvenient, and 
may be entirely omitted for the sake of the more effec- 
tual remedy, blistering. 

Very early in the disease, a blister should be applied 
as near to the pained part as possible. But as, when 
the irritation of a blister is present, it renders bleeding 
less effectual, so the application of the blister should be 
delayed till a bleeding shall have been employed. If 
the disease be moderate, the blister may be applied im- 
mediately after the first bleeding; but if the disease be 
violent, and it is presumed that a second bleeding may 
be necessary soon after the first, it will then be proper 
to delay the Blister till after the second bleeding, when 
it may be supposed that any further bleeding may be 
postponed till the irritation arising from the blister shall 
have ceased. It may be frequently necessary in this 

* As a nauseating medicine, and, at the same time, to produce a diapho- 
resis, administer every hour, or oftener, the sixth of a grain of tartarized 
antimony, combined with ten or twelve grains of nitre. This constitutes 
also an excellent expectorant. 

Although copious purging is not requisite, nor, perhaps, proper, in pe- 
ripneumony, yet the bowels should be kept perfectly free from irritating 
fxces. This purpose may be answered by injections and gentle laxatives. 

Our author erroneously represents peripneumotvy as a disease confined 
to an advanced period of life. Some of the severest attacks we have ever 
witnessed have been in young persons — a few of them even under the age 
of puberty. 



268 PRACTICE OF PHYSIC. 

disease to repeat the blistering: and in that case the 
plasters should always be applied somewhere on the 
thorax, for, when applied to more distant parts, they 
have little effect. The keeping the blistered parts open, 
and making what is called a perpetual blister, has much 
less effect than a fresh blistering* 

373. As this disease often terminates by an expecto- 
ration, so various means of promoting this have been 
proposed: but none of them appear to be very effectual; 
and some of them being acrid stimulant substances, 
cannot be very safe. 

The gums usually employed seem too heating: squills 
seem to be less so; but they are not very powerful, and 
sometimes inconvenient by the constant nausea they 
induce. 

The volatile alkali may be of service as an expecto- 
rant; but it should be reserved for an advanced state of 
the, disease. 

Mucilaginous and oily demulcents appear to be useful, 
by allaying that acrimony of the mucus which occasions 
too frequent coughing; and which coughing prevents 
the stagnation and thickening of the mucus, and thereby 
its becoming mild. 

The receiving into the lungs the steams of warm water 
impregnated with vinegar, has often proved useful in 
promoting expectoration. 

But, of all other remedies the most powerful for this 
purpose, are antimonial medicines, given in nauseating 
doses, as in (179). Of these, however, I have not found 
the kermes mineral more efficacious than emetic tartar, 

* It is worse than useless — it is injurious, to apply blisters in peripneu- 
mony, before the pulse has been considerably reduced by means of blood- 
letting. But when, by the previous treatment, the febrile action has been 
sufficiently weakened, blistering becomes an invaluable remedy. The 
plaster should be applied as near as possible to the part affected, and the 
blister kept open until the pain be removed. 



PRACTICE OF PHYSIC. 269 

or antimonial wine; and the dose of the kermes is much 
more uncertain than that of the others.* 

374. Though a spontaneous sweating often proves 
the crisis of this disease, it ought not to be excited by 
art, unless with much caution. At least I have not 
found it either so effectual or safe as some writers have 
alleged. When, after some remission of the symptoms, 
spontaneous sweats of a proper kind arise, they may be 
encouraged; but it ought to be without much heat, and 
without stimulant medicines. If, however, the sweats 
be partial and clammy only, and a great difficulty of 
breathing still remain, it will be very dangerous to en- 
courage them. 

375. Physicians have differed much in opinion with 
regard to the use of opiates in pneumonic inflammation. 
To me it appears, that, in the beginning of the disease, 
and before bleeding and blistering have produced some 
remission of the pain and of the difficulty of breathing, 
opiates have a very bad effect, by their increasing the 
difficulty of breathing, and other inflammatory symp- 
toms. But in a more advanced state of the disease, 
when the difficulty of breathing has abated, and when 
the urgent symptom is a cough, proving the chief cause 
of the continuance of the pain and of the want of sleep, 
opiates may be employed with great advantage and safe- 
ty. The interruption of the expectoration, which they 
seem to occasion, is for a short time only: and they 

* As an expectorant, the decoction of Seneka may be usefully employed. 
From the exhibition of squills, we have never derived much advantage in 
this disease. Partly as an expectorant, and partly as a diaphoretic, an infu- 
sion of the Virginia snake-root may be administered with good effect. 

Mucilaginous demulcents are useful ; but oily ones injurious. The latter 
produce too much excitement. 

We place no reliance on the inhalation of steams of any description. If 
our patient be weak, the practice is inconvenient; and if not, other things 
may be resorted to that are more advantageous. The best medium that can 
be respired, is atmospheric air free from impurities. 



270 PRACTICE OF PHYSIC. 

seem often to promote it, as they occasion a stagnation 
of what was by frequent coughing dissipated insensibly, 
and therefore give the appearance of what physicians 
have called Concocted Matter.* 



CHAPTER VII. 



OF THE PERIPNEUMONIA NOTHA, OR BASTARD 
PERIPNEUMONY.f 

376. A DISEASE under this name is mentioned in 
some medical writings of the sixteenth century; but it 



* Opiates should not be administered in this disease, until the symptoms 
of pyrexia are greatly weakened. To allay pulmonary irritation, and pro- 
cure rest, they then become an invaluable remedy. We think them most 
effectual, when combined with the mucilage of gum arabic. 

In protracted cases of peripneumony, the cure may be accelerated, and, 
at the same time, rendered more certain and complete, by gently touching 
the mouth with mercury. To effect this, a grain of calomel may be added 
to each of the nitro-antimonial powders ; and, if requisite, a few drops of 
laudanum given occasionally, to prevent them from purging. 

In the treatment of peripneumony, it is of the utmost importance that the 
disease be completely and radically cured. If any remnant of the cough be 
left, it facilitates a relapse, or endangers, perhaps, consumption. This symp- 
tom is most certainly removed, by carrying blood-letting to the proper ex- 
tent. For that remedy nothing else can serve as a substitute. 

f Our author's description of this disease is excellent ; and to what he has 
said respecting the treatment of it, we have but little to add. We are con- 
vinced that, in many cases, we believe, generally, blood-letting may be car- 
ried further than he is willing to admit. In relation to this remedy, how- 
ever, the state of the pulse and other symptoms, which it belongs to the 
practitioner to examine for himself, must always govern. In a few instances 
we have advantageously repeated blood-letting several times. The appear- 
ance of the blood, and the effect produced by drawing it, can seldom fail to 
give correct information as to the propriety of repeatirfg the operation. 

We are of opinion, that a principal reason why such cautions are usually 
enjoined, with regard to blood-letting in peripneumonia notha is, because it 
is a disease of elderly persons. But that circumstance furnishes no solid 
ground of objection against a liberal use of the remedy. In many instances, 



PRACTICE OF PHYSIC. 21 1 

is very doubtful if the name was then applied to the 
same disease to which we now apply it. It appears to 
me, that unless some of the cases described under the 
title of Catarrhus Suffocativus be supposed to have been 
of the kind I am now to treat of, there was no descrip- 
tion of this disease given before that by Sydenham, un- 
der the title I have employed here. 

377. After Sydenham, Boerhaave was the first who 
in a system took notice of it as a distinct disease; and 
he has described it in his aphorisms, although with 
some circumstances different from those in the descrip- 
tion of Sydenham. Of late, Mr. Lieutaud has with great 
confidence asserted, that Sydenham and Boerhaave had, 
under the same title, described different diseases; and 
that, perhaps, neither of them had on this subject deli- 
vered any thing but the hypothesis. 

the diseases of such persons are known to call for blood-letting to a great 
extent. 

Peripneumonia notha being, in fact, a kind of apoplexy of the lungs, we 
do not perceive how it can be effectually treated without the free use of 
the lancet. 

We have been told, that much relief, and even permanent advantage, 
have been derived in this disease, from breathing the fumes of rosin, and the 
steams of warm water. Of these remedies, however, we have had no ex- 
perience. 

Although we would not hesitate to repeat " full vomiting" several times 
in this disease, if called for by a continuance of unfavourable symptoms, we 
think that circumspection is necessary, as to repeating it very "frequentli/." 
It sometimes debilitates more than blood-letting. 

As an expectorant in peripneumonia notha, the decoction of seneka has 
been advantageously employed. So has syrup of squills. 

Ulistcring and sweating are cardinal remedies in it. No expedient should 
be omitted that is in any measure calculated to determine to the surface. 
Small doses of ipecacuanha, repeatedly exhibited, are highly useful. 

When, notwithstanding every effort to break its force, the disease conti- 
nues obstinate, and great weakness begins to ensue, recourse must be had to 
stimulants and cordials. Of these, wine whey, musk, and volatile alkali, may 
be mentioned as among the most efficacious. They must be given in libe- 
ral and repeated doses. 

The ventilation of the patient's chamber .should be free ; but cold air 
must be cautiously excluded. 



212 PRACTICE OF PHYSIC. 

378. Notwithstanding this bold assertion, I am hum- 
bly of opinion, and the Baron Van Swieten seems to 
have been of the same, that Sydenham and Boerhaave 
did describe, under the same title, one and the same 
disease. Nay, I am further of opinion, that the dis- 
ease described by Mr. Lieutaud himself, is not essen- 
tially different from that described by both the other 
authors. Nor will the doubts of the very learned, but 
modest Morgagni, on this subject, disturb us, if we con- 
sider, that while very few describers of diseases either 
have it in their power, or have been sufficiently attentive 
in distinguishing between the essential and accidental 
symptoms of disease; so, in a disease which may have 
not only different, but a greater number of symptoms, 
in one person than it has in another, we need not won- 
der that the descriptions of the same disease by differ- 
ent persons should come out in some respects different. 
I shall, however, enter no further into this controversy; 
but endeavour to describe the disease as it has appeared 
to myself: and, as I judge, in the essential symptoms, 
much the same as it has appeared to all the other au- 
thors mentioned. 

379. This disease appears at the same seasons that 
other pneumonic and catarrhal affections commonly do; 
that is, in autumn and spring. Like these diseases also, 
it is seemingly occasioned by sudden changes of the 
weather from heat to cold. It appears, also, during the 
prevalence of contagious catarrhs; and it is frequently 
under the form of the Peripneumonia Notha that these 
catarrhs prove fatal to elderly persons. 

This disease attacks most commonly persons some- 
what advanced in life, especially those of a full phleg- 
matic habit; those who have before been frequently lia- 
ble to catarrhal affections; and those who have been 



PRACTICE OF PHYSIC. 273 

much addicted to the large use of fermented and spi- 
rituous liquors. 

The disease commonly comes on with the same symp- 
toms as other febrile diseases; that is, with alternate 
chills and heats; and the symptoms of pyrexia are some- 
times sufficiently evident; but in most cases these are 
very moderate, and in some hardly at all appear. With 
the first attack of the disease, a cough comes on; usu- 
ally accompanied with some expectoration, and in many 
cases, there is a frequent throwing up of a considerable 
quantity of viscid opaque mucus. The cough often be- 
comes frequent and violent; is sometimes accompanied 
with a rending headach; and, as in other cases of cough, 
a vomiting is sometimes excited by it. The face is 
sometimes flushed, and some giddiness or drowsiness 
often attends the disease. A difficulty of breathing, with 
a sense of oppression, or straitening in the chest, with 
some obscure pains there, and a sense of lassitude over 
the whole body, very constantly attend this disease. The 
blood drawn in this disease, shows a buffy surface, as in 
other inflammatory affections. 

The disease has often the appearance only of a more 
violent catarrh, and after the employmeMt of some reme- 
dies, is entirely relieved by a free a»d copious expecto- 
ration. In other cases, however the feverish and ca- 
tarrhal symptoms are at fir^ very moderate, and even 
slight; but after a few <&ys these symptoms suddenly 
become considerable, and put an end to the patient's 
life when the indications of danger were before very 
little evident. 

380. From the different circumstances in which this 
disease appears, the pathology of it is difficult. It is 
certainly often no other at first than a catarrhal affection, 
which, in elderly persons, is frequently attended with a 
large afflux of mucus to the lungs; and it was on this 

vol. i. Mm 



274 PRACTICE OF PHYSIC. 

footing that Sydenham considered it as only differing 
in degree from his Febris Hyemalis. A catarrh, how- 
ever, is strictly an affection of the mucus membrane and 
follicles of the bronchias alone: but it may readily have, 
and frequently has, a degree of pneumonic inflamma- 
tion joined to it; and in that case may prove more pro- 
perly the peculiar disease we treat of here. But further, 
as pneumonic inflammation very often produces an effu- 
sion of serum into the bronchiae, (348.) so this, in elderly 
persons, may oGcur in consequence of a slight degree 
of inflammation; and when it does happen, will give ex- 
quisite and fatal cases of the peripneumonia notha. 

381. After this attempt to establish the pathology, the 
method of cure in the different circumstances of the 
disease will not be difficult. 

In case the fever, catarrhal and pneumonic symptoms, 
are immediately considerable, a blood-letting will cer- 
tainly be proper and necessary: but, where these symp- 
toms are moderate, a blood-letting will hardly be requi- 
site; and when an effusion is to be feared, the repetition 
of blood-Mting may prove extremely hurtful. 

In all cast*, the remedies chiefly to be depended upon 
are vomiting ai^i blistering. 

Full vomiting n*y be frequently repeated, and nau- 
seating doses ought to be constantly employed. 

Purging may perhaps \i e useful; but as it is seldom 
so in pneumonic affections, nothing but gentle laxatives 
are here necessary. 

In all the circumstances of this disease, the antiphlo- 
gistic regimen is proper; cold is to be guarded against; 
but much external heat is to be as carefully avoided. 

382. If a person sweats easily, and it can be brought 
out by the use of mild tepid liquors only, thf practice 
may in such persons be tried. See Morgagni de Sed. 
et Caus. Epist. xiii. Art. 4. 



PRACTICE OF PHYSIC. 215 

383. 1 might here, perhaps, give a separate section on 
the Carditis and Pericarditis, or the inflammations of the 
Heart and Pericardium; but they hardly require a par- 
ticular consideration. An acute inflammation of the pe- 
ricardium is almost always a part of the same pneumo- 
nic affection I have been treating of; and is not always 
distinguished by any different symptoms: or, if it be, 
does not require any different treatment. The same may 
be said of an acute inflammation of the heart itself; and 
when it happens that the one or the other is discovered 
by the symptoms of palpitation or syncope, no more 
will be implied than that the remedies of pneumonic 
inflammation should be employed with greater diligence. 

From dissections, which show the heart and pericar- 
dium affected with erosions, ulcerations, and abscesses, 
we discover, that these parts had been before affected 
with inflammation ; and that in cases where no symptoms 
of pneumonic inflammation had appeared: it may there- 
fore be alleged, that those inflammations of the heart 
and pericardium should be considered as diseases inde- 
pendent of the pneumonic. This indeed is just; but 
the history of such cases proves that those inflamma- 
tions had been of a chronic kind, and hardly discovering 
themselves by any peculiar symptoms; or if attended 
with symptoms marking an affection of the heart, these 
were however such as have been known frequently to 
arise from other causes than inflammation. There is, 
therefore, upon the whole, no room for our treating 
more particularly of the inflammation of the heart or 
pericardium. 



276 PRACTICE OF PHYSIC. 



CHAPTER VIII. 

OF THE GASTRITIS, OR INFLAMMATION OF THE 
STOMACH.* 

384. AMONG the inflammations of the abdominal re- 
gion, I have given a place in our Nosology to the Peri- 
tonitis; comprehending under that title, not only the 
inflammations affecting the peritonaeum lining the ca- 

* Our experience in gastritis, strictly so called, has been but limited. 
The cases we have seen have arisen from the drinking 1 of cold water, from 
mechanical injuries, or from the intemperate use of ardent spirits, one from 
coirosive sublimate, swallowed by mistake, and another from an excessive 
dose of the spirits of turpentine. In all of them the symptoms have been 
the same — pyrexia, with a small, but frequent, quick, hard, and corded 
pulse, a sensation of agony in the epigastric region, soreness to the touch, 
a perceptible degree of tension, such a morbid irritability of stomach as led 
to the rejection of every thing that was swallowed, and a prostration of 
strength greater than we have witnessed in any other of the Phlegmasia:. 
This prostration manifests conclusively the powerful sympathies that exist 
between the stomach and the other parts of the system. 

The practice pursued in these cases was, blood-letting to a considerable 
extent — not in large quantities at once, but frequently repeated, blistering 
very extensively on the region of the part affected, and purging by means 
of active injections. By the mouth nothing was exhibited but drinks, and 
those very sparingly. The liquids that answered best for this purpose were, 
simple water, a very thin mucilage of gum arabic, two-milk whey, and sweet 
milk, diluted with about twice its quantity of water. Although these arti- 
cles were frequently rejected, they occasioned less distress, and were 
longer and more generally retained than any thing else. 

Anodyne injections gave a considerable respite from suffering, and pro- 
cured for the sick some rest during the night, without adding to the py- 
rexia, or being productive, in any respect, of injurious effects. They were, 
therefore, considered as an important remedy -. for, when labouring under 
gastritis, sleep is the only restorative the unfortunate patient is permitted 
to enjoy. Each injection was composed of three grains of opium, dissolved 
in a small quantity of water, and mixed with a gill of the mucilage of gum 
arabic. 

In this complaint it is of the utmost moment to keep up the peristaltic 
motion of the bowels, as it carries off from the stomach such secreted and 
other matters, as might prove offensive and injurious irritants. It operates 
somewhat like a topical evacuation, reducing the inflammatory excitement 
of the part. 



PRACTICE OF PHYSIC. 277 

vity of the abdomen, but also those affecting the exten- 
sions of this membrane in the omentum and mesentery. 
It is not, however, proposed to treat of them here, be- 
cause it is very difficult to say by what symptoms they 
are always to be known; and farther, because when 
known, they do not require any remedies beside those 
of inflammation in general. I proceed, therefore, to 
treat of those inflammations, which, affecting viscera of 
peculiar functions, both give occasion to peculiar symp- 
toms, and require some peculiarities in the method of 
cure; and I shall begin with the inflammation of the 
stomach. 

385. The inflammation of the stomach is of two 
kinds, Phlegmonic, or Erythematic* The first may 
be seated in what is called the Nervous Coat of the 
stomach, or in the peritonaeum investing it. The se- 
cond is always seated in the villous coat and cellular 
texture immediately subjacent. 

386. The phlegmonic inflammation of the stomach, 
or what has been commonly treated of under the title 
of Gastritis, is known by an acute pain in some part of 
the region of the stomach, attended with pyrexia, with 
frequent vomiting, especially upon occasion of any thing 
being taken down into the stomach, and frequently with 
hickup. The pulse is commonly small and hard; and 
thsre is a greater loss of strength in all the functions of 
the body, than in the case of almost any other inflam- 
mation. 

387. This inflammation may be produced by various 
causes; as, by external contusion; by acrids of various 
kinds taken into the stomach; frequently by very cold 
drink taken into it while the body is very warm; and 

* This is a new term; but whoever considers what is said in 274. will, 
I expect, perceive the propriety, and even the necessity of it. 

Cullex. 



278 PRACTICE OF PHYSIC. 

sometimes by over-distention, from the having taken in 
a large quantity of food of difficult digestion. All these 
may be considered as external causes; but the disease 
sometimes arises also from internal causes not so well 
understood. It may arise from inflammations of the 
neighbouring parts communicated to the stomach, and 
is then to be considered as a symptomatic affection only. 
It may arise also from various acrimonies generated 
within the body, either in the stomach itself, or in other 
parts, and poured into the cavity of the stomach. These 
are causes more directly applied to the stomach; but 
there are perhaps others originating elsewhere, and af- 
fecting the stomach only sympathetically. Such may be 
supposed to have acted in the case of putrid fevers and 
exanthematic pyrexia; in which, upon dissection, it has 
been discovered that the stomach had been affected 
with inflammation.* 

388. From the sensibility of the stomach, and its 
communication with the rest of the stystem, it will be 
obvious, that the inflammation of this organ, by what- 
ever causes produced, may be attended with fatal con- 
sequences. In particular, by the great debility which 
such an inflammation suddenly produces, it may quickly 
prove fatal without running the common course of in- 
flammations. 

When it lasts long enough to follow the ordinary 
course of other inflammations, it may terminate by re- 

* The inflammation which appears in the stomach in malignant, or, what 
our author calls " putrid fevers, and exanthematic pyrexia," shows clearly, 
.is we have heretofore stated, that those diseases have their primary seat in 
that organ. It is produced, not by any " acrimonies generated in the body, 
and poured into the cavity of the stomach," but by the original poisons of 
those disejses making their way into that organ, and perpetrating on it lo- 
cally thei'rSideleterious effects. 

If the disease arise from the action of any poison that can be easily neu- 
tralized, and which has not yet been evacuated, — an acid or an alkali, for ex- 
ample — let its opposite, or neutralize^ be immediately thrown into the sto- 
mach. 



PRACTICE OF PHYSIC. 279 

solution, gangrene, or suppuration. The scirrhosities 
which are often discovered affecting the stomach, are 
seldom known to be the consequences of inflammation. 

389. The tendency of this disease to admit of resolu- 
tion, may be known, by its having arisen from no vio- 
lent cause; by the moderate state of the symptoms; and 
by a gradual remission of these, especially in conse- 
quence of remedies employed in course of the first, or 
at farthest, the second week of the disease. 

390. The tendency to suppuration may be known by 
the symptoms continuing, in a moderate degree, for 
more than one or two weeks; and likewise by a consi- 
derable remission of the pain, while a sense of weight 
and an anxiety still remain. 

When an abscess has been formed, the frequency of 
the pulse is at first abated; but soon after, it is again 
increased, with frequent cold shiverings, and with mark- 
ed exacerbations in the afternoon and evening, followed 
by night sweatings, and other symptoms of hectic fever. 
These at length prove fatal, unless the abscess open into 
the cavity of the stomach, the pus be evacuated by vo- 
miting, and the ulcer soon heal. 

391. The tendency to gangrene may be suspected 
from the violence of the symptoms not yielding to the 
remedies employed during the first days of the disease: 
and that a gangrene has already begun, may be known 
from the sudden remission of the pain, while the fre- 
quency of the pulse continues, and at the same time be- 
comes weaker, accompanied with other marks of an in- 
creasing debility in the whole system. 

392. From the dissection of dead bodies it appears, 
that the stomach very often has been affected Vfith in- 
flammation, when the characteristic symptoms of it 
(386,) had not appeared; and therefore it is very diffi- 



280 PRACTICE OF PHYSIC. 

cult to lay down any general rules for the cure of this 
disease. 

393. It is only in the case of phlegmonic inflamma- 
tion, as characterized in 386., that we can advise the 
cure or resolution to be attempted by large and repeated 
bleedings employed early in the disease: and we are not 
to be deterred from these by the smallness of the pulse; 
for after bleeding it commonly becomes fuller and softer. 
After bleeding, a blister ought to be applied to the re- 
gion of the stomach; and the cure will be assisted by 
fomentations of the whole abdomen, as well as by fre- 
quent emollient and laxative glysters. 

394. In this disease, the irritability of the stomach 
will not admit of any medicines being thrown into it; 
and if any internal medicines can be supposed neces- 
sary, they must be exhibited in glysters. The giving of 
drink may be tried; but it ought to be of the very mild- 
est kind, and in very small quantities at a time. 

395. Opiates, in whatever manner exhibited, are very 
hurtful during the first days of the disease; but when its 
violence shall have abated, and when the violence of the 
pain and vomiting recur at intervals only, opiates given 
in glysters may be cautiously tried, and sometimes have 
been employed with advantage. 

396. A tendency to suppuration, in this disease, is to 
be obviated by the means just now proposed. After a 
certain duration of the disease, it cannot be prevented 
by any means whatever; and when actually begun must 
be left to nature; the business of the physician being 
only to avoid all irritation. 

397. A tendency to gangrene can be obviated in no 
other way than by the means suggested, (393.) employed 
early in the disease; and, when it does actually super- 
vene, admits of no remedy. 



PRACTICE OF PHYSIC. 281 

398. Erythematic inflammations of the stomach, are 
more frequent than those of the phlegmonic kind. It 
appears at least, from dissections, that the stomach has 
often been affected with inflammation, when neither 
pain nor pyrexia had before given any notice of it; and 
such inflammation 1 apprehend to have been chiefly of 
the erythematic kind. This species of inflammation also 
is especially to be expected from acrimony of any kind 
thrown into the stomach; and would certainly occur 
more frequently from such a cause, were not the inte- 
rior surface of this organ commonly defended by mucous 
exuding in large quantities from the numerous follicles 
placed immediately under the villous coat. Upon many 
occasions, however, the exudation of mucus is prevent- 
ed, or the liquid poured out is of a less viscid kind, so 
as to be less fitted to defend the subjacent nerves; and 
it is in such cases that matters, even of moderate acri- 
mony, may produce an erythematic affection of the 
stomach. 

399. From what has been said, it must appear that an 
erythematic inflammation of the stomach may frequently 
occur; but will not always discover itself, as it some- 
times takes place without pyrexia, pain, or vomiting. 

400. There are cases, however, in which it may be 
discovered. The affection of the stomach sometimes 
spreads into the oesophagus, and appears in the pharynx, 
as well as on the whole internal surface of the mouth. 
When, therefore, an erythematic inflammation affects 
the mouth and fauces, and when at the same time there 
shall be in the stomach an unusual sensibility to all 
acrids, with a frequent vomiting, there can be little 
doubt of the stomach being affected with the same in- 
flammation that has appeared in the fauces. Even when 
no inflammation appears in the fauces, yet if some degree 
of pain be felt in the stomach, if there be a want of 

vol. i. n n 



,282 PRACTICE OF PHYSIC 

appetite, an anxiety, frequent vomiting, an unusual sen- 
sibility, with respect to acrids, some thirst, and frequency 
of pulse, there will then be room to suspect an erythe- 
matic inflammation of the stomach; and we have known 
such symptoms, after some time, discover their cause 
more clearly, by the appearance of the inflammation in 
the fauces or mouth. Erythematic inflammation is often 
disposed to spread from one place to another on the 
same surface; and, in doing so, to leave the place it had 
at first occupied. Thus, such an inflammation has been 
known to spread successively along the whole course of 
the alimentary canal, occasioning in the intestines diar- 
rhoea, and in the stomach vomitings; the diarrhcea ceasing 
when the vomiting came on, or the vomitings upon the 
coming on of the diarrhoea. 

401. When an erythematic inflammation of the sto- 
mach shall be discovered, it is to be treated differently, 
according to the difference of its causes and symptoms. 

When it is owing to acrid matters taken in by the 
mouth, and when these may be supposed still present 
in the stomach, they are to be washed out by throwing 
in a large quantity of warm and mild liquids, and by 
exciting vomiting. At the same time, if the nature of 
the acrimony and its proper corrector be known, this 
should be thrown in; or if a specific corrector be not 
known, some general demulcents should be employed. 

402. These measures, however, are more suited to 
prevent the inflammation, than to cure it after it has 
taken place. When this last may be supposed to be the 
case, if it be attended with a sense of heat, with pain 
and pyrexia, according to the degree of these symptoms, 
the measures proposed in 393. are to be more or less 
employed. 

403. When an erythematic inflammation of the sto- 
mach has arisen from internal causes, if pain and 



PRACTICE OF PHYSIC. 283 

pyrexia accompany the disease, some bleeding in per- 
sons not otherwise weakened, may be employed; but, 
as the affection often arises in putrid diseases, and in 
convalescents from fever; so in these cases, bleeding is 
inadmissible; all that can be done being to avoid irrita- 
tion, and to throw into the stomach what quantity of 
acids, and of acescent aliments, it shall be found to bear. 
In some conditions of the body, in which this disease 
arises, the Peruvian bark and bitters may seem to be 
indicated: but an erythematic state of the stomach does 
not commonly allow of them. 



CHAPTER IX. 



OF THE ENTERITIS, OR INFLAMMATION OF THE 
INTESTINES.* 

404. THE inflammation of the intestines, like that of 
the stomach, maybe either phlegmonic or erythematic; 
but on the subject of the latter, I have nothing to add 

* As far as we may rely on our own experience, we think that the prin- 
cipal difference between the treatment of this and the preceding disease is, 
that here there is somewhat more room to operate on the stomach, and 
blood-letting may be carried to a greater extent. 

In the first stages of enteritis, however, it is unsafe to throw purgative 
medicines into the stomach, in as much as they are likely to be either re- 
jected, or to remain and fail of their effect ; in either of which cases their 
irritation does mischief. The bowels must be moved, therefore, by means 
of injections ; and it is important that they be frequently and effectually 
cleared of their irritating contents. Injections of cold water, besides being 
grateful and refreshing to the patient, are usually productive of a purgative 
effect They are, perhaps, therefore, on the whole, the most useful that 
can be employed; particularly if they be quickened in their action by an 
addition of Epsom or Glauber's salts. 

Should these, however, fail in opening the bowels, the antimonial in- 
jection will probably succeed. This consists of twenty grains of tartarized 
antimony dissolved in a pint of water, or an equal quantity of the mucilage of 
gum arabic. If carefully thrown into the rectum, it rarely fails in procuring 
a speedy and copious evacuation. 



£84 PRACTICE OF PHYSIC. ' 

to what has been said in the last chapter; and shall here, 
therefore, treat of the phlegmonk inflammation only. 

405. This inflammation may be known to be present, 
by a fixed pain of the abdomen, attended with pyrexia, 
costivenessand vomiting. Practical writers mention the 
pain in this case as felt in different parts of the abdomen, 
according to the different seat of the inflammation; and 
so, indeed, it sometimes happens; but very often the pain 
spreads over the whole belly, and is felt more especially 
about the navel 

406. The Enteritis and Gastritis arise from like causes; 
but the former, more readily than the latter, proceeds 
from cold applied to the lower extremities,, or to the 
belly itself. The enteritis has likewise its own peculiar 
causes, as supervening upon the spasmodic colic, in- 
carcerated hernia, and volvulus. 

407. Inflammations of the intestines have the same 
terminations as those of the stomach; and, in both cases, 
the several tendencies are to be discovered by the same 
symptoms (389. 391). 

408. The cure of the enteritis is, in general, the same 
with that of the gastritis; (393. et seq.): but in the ente- 
ritis there is commonly more access to the introduction 
of liquids, of acid, acescent, and other cooling remedies, 
and even of laxatives. As, however, a vomiting so fre- 
quently attends this disease, care must be taken not to 
excite that vomitingrby either the quantity or the qua- 
lity of any thing thrown into the stomach. 

The same observation with respect to the use of opi- 
ates is to be made here as in the case of gastritis. 

When the bowels have been thoroughly emptied, the anodyne injection 
may be used here with nearly the same advantage as in inflammation of the 
stomach 

But it is unnecessary to dwell any longer on this complaint. The physi- 
cian who understands the treatment of gastritis, cannot fail in that of en- 
teritis. 



PRACTICE OF PHYSIC. 285 

409. Under the title of Enteritis, it has been usual 
with practical writers to treat of the remedies proper for 
the colic, and its higher degree named Ileus: but, al- 
though it be true that the enteritis and colic do fre- 
quently accompany each other, I still hold them to be 
distinct diseases, to be often occurring separately, and 
accordingly to require and admit of different remedies. I 
shall therefore delay speaking of the remedies proper 
for the colic, till I shall come to treat of this disease in 
its proper place. 

410. What might be mentioned with respect to the 
suppuration or gangrene occurring in the enteritis, may 
be sufficiently understood from what has been said on 
the same subject with respect to the gastritis. 



CHAPTER X. 



OF THE HEPATITIS, OR INFLAMMATION OF THE 
LIVER.* 

411. THE inflammation of the liver seems to be of 
two kinds: the one acute, the other chronic. 

412. The acute is attended'with pungent pain; consi- 

* Although the contents of this chapter cannot be denied to be correct 
and judicious, as far as they go, we find no ground to conclude from them, 
that Dr. Cullen had ever much experience in inflammations of the liver. 
We are almost compelled, on the other hand, to believe the reverse. 

The doubts which the professor expresses, and the want of knowledge 
he manifests, on the subject of chronic hepatitis, are to be attributed, we 
presume, to his having always lived and practised in a healthy country, 
where that form of disease but rarely made its appearance. Here, and in 
warm climates, the complaint is almost as well known and as easily distin- 
guished, as small pox or measles, cholera morbus or intermitting fever. 

In acute hepatitis, properly so called, the symptoms of which our author 
has very accurately enumerated, the mode of treatment differ sin no material 
point from that which we pursue in other violent cases of phlegmasia. As 
the disease is obstinate and unusually rapid in its progress towards sup- 



286 PRACTICE OF PHYSIC. 

derable pyrexia; a frequent, strong, and hard pulse; and 
high coloured urine. 

413. The chronic hepatitis very often does not exhi- 

puration, it calls for practice of great energy. Blood-letting, in particular, 
must be carried, in a given time, to an extent not common, and scarcely 
warranted in other complaints. From a robust and vigorous subject, we 
have known nearly four pounds of blood to be taken in a day, not 
onlv with safety, but evident advantage. We have reason to believe that 
a smaller quantity would have been altogether below the exigency of the 
disease. While the pulse remains full and strong, and the pain in the side 
pungent, blood-letting is the only remedy on which we can rely. In the 
mean time, however, it should be aided by copious purging with calomel, 
quickened in its action by jalap and a strong infusion of senna. The infusion 
of senna, with nearly as much of Glauber's or Epsom salts as it will hold in 
solution, constitutes also an excellent purge. 

While these operations are going forward, cups or leeches, or both, 
should be liberally applied to the region of the liver, and a large blister laid 
on the same, as soon as the febrile action is sufficiently reduced But if 
blistering be resorted to at too early a period, besides standing in the way 
of topical blood-letting, it can scarcely fail on other grounds to be produc- 
tive of mischief. 

These remedies, connected with a rigid enforcement of the antiphlogistic 
regimen, constitute our reliance in acute hepatitis. The minor aids deemed 
necessary may be varied according to the judgment and experience of the 
practitioner. After the inflammation has been sufficiently reduced, it will 
be the safest practice, to remove the disease entirely by a gentle mercurial 
ptyalism, to be continued for some time. 

In chronic hepatitis venesection is also essential ; but must not be pushed 
to the same extent in a given time. There exists, however, scarcely any 
complaint in the course of which so large a quantity of blood has been taken 
from the patient with advantage, as in some cases of that which we are now 
considering. But, as the disease is chronic, such must be the remedies, 
gradually, but firmly and perseveringly employed. 

Here also the application of cups to the region of the liver is highly use- 
ful : but the most important topical remedy is a perpetual blister ; or, what 
is better still, a caustic or a seton. From the latter remedy, in particular, we 
have derived effects unexpectedly salutary. 

But in the treatment of chronic hepatitis, our chief reliance is on a gentle 
but continued mercurial ptyalism. Should the system be likely to sink un- 
der this remedy, let it be discontinued, for a time, and then recommenced ; 
and let this plan be steadily pursued, until every symptom of the complaint 
shall have disappeared. 

If the season be mild, and the febrile action very moderate, the patient 
maybe allowed to take gentle exercise in the open air. But no one, under 
the influence of mercury, should ever venture out of his chamber in damp 
or cold weather. It is to a neglect of this precaution that we are to attri- 



PRACTICE OF PHYSIC. 287 

bit any of these symptoms; and it is only discovered to 
have happened, by our finding in the liver, upon dissec- 
tion, large abscesses, which are presumed to be the ef- 
fect of some degree of previous inflammation. As this 
cnronic inflammation is seldom to be certainly known, 
and therefore does not lead to any determined practice, 
we omit treating of it here, and shall only treat of what 
relates to the acute species of the hepatitis. 

414. The acute hepatitis may be known by a pain 
more or less acute in the right hypochondrium, increased 
by pressing upon the part. The pain is very often in 
such a part of the side as to make it appear like that of 
a pleurisy; and frequently, like that too, is increased on 
respiration. The disease is, in some instances, also at- 
tended with a cough, which is commonly dry, but some' 
times humid: and when the pain thus resembles that of 
a pleurisy, the patient cannot lie easily except upon the 
side affected. 

bute the frequent failure of that remedy, and the many injurious effects 
that occasionally result from the use of it. When exhibited under proper 
circumstances, there is no remedy more perfectly safe than mercury; nor is 
there any one more dangerous if used indiscreetly. 

Another remedy, which lias acquired a high reputation in the treatment 
of chronic hepatitis, is the nitric aeid. It may be given, in divided doses, to 
the amount of from one to three or four drachms in twenty-four hours. A 
pleasant formula is, to make it into a julep with mucilage of gum arabic, 
mint, or lavender water, and loaf sugar. 

In the use of this remedy, our experience is limited. It is recommended, 
therefore, on the testimony of others, rather than on our own. personal 
knowledge. 

With some physicians of eminence, the expressed juice of the dande- 
lion, taken in the quantity of from a gill to half a pint a day, is ia high 
reputation. 

When all other remedies have failed of a perfect cure, we have known 
chronic hepatitis completely removed, by the long continued action of a se- 
ton in the right hypochondriac region. 

To success in this disease, under any plan of treatment, the use of flan- 
nel next the skin, and an adherence to the antiphlogistic regimen, is ne- 
cessary. 

As a laxative and an alterative, the long continued use of pills, composed 
of rhubarb and castile soap, is highly recommended. 



288 PRACTICE OF PHYSIC. 

In every kind of acute hepatitis, the pain is often ex- 
tended to the clavicle, and to the top of the shoulder. 
The disease is attended sometimes with hickup, and 
sometimes with vomiting. Many practical writers have 
mentioned the jaundice, or a yellow colour of the skin 
and eyes, as a very constant symptom of the hepatitis; 
but experience has shown, that it may often occur with- 
out any such symptom. 

415. The remote causes of hepatitis are not always to 
be discerned, and many have been assigned on a very 
uncertain foundation. The following .seem to be fre- 
quently evident. 1. External violence from contusions 
or falls, and especially those which have occasioned a 
fracture of the cranium. 2. Certain passions of the mind. 
3. Violent summer heats. 4. Violent exercise 5. Inter- 
mittent and remittent fevers. 6. Cold applied externally, 
or internally; and therefore in many cases the same 
causes which produce pneumonic inflammation, pro- 
duce hepatitis; and whence also the two diseases are 
sometimes joined together. 7. Various solid concretions 
or collections of liquid matter, in the substance of the 
liver, produced by unknown causes. Lastly, the aeute 
is often induced by a chronic inflammation of this 
viscus. 

416. It has been supposed, that the hepatitis may be 
an affection either of the extremities of the hepatic ar- 
tery, or of those of the vena portarum; but of the last 
supposition there is neither evidence nor probability. 

417. It seems probable, that the acute hepatitis is 
always an affection of the external membrane of the 
liver; and that the parenchymatic is of the chronic 
kind. The acute disease may be seated either on the 
convex or on the concave surface of the liver. In the 
former case, a more pungent pain and hickup may be 
produced, and the respiration is more considerably af- 



PRACTICE OF PHYSIC. 289 

fected. In the latter, there occurs less pain ; and a vo- 
miting is produced, commonly by some inflammation 
communicated to the stomach. The inflammation of 
the concave surface of the liver, may be readily com- 
municated to the gall-bladder and biliary ducts; and 
this perhaps is the only case of idiopathic hepatitis at- 
tended with jaundice. 

418. The hepatitis, like other inflammations, may 
end by resolution, suppuration, or gangrene; and the 
tendency to the one or the other of these events, may 
be known from what has been delivered above. 

419. The resolution of hepatitis is often the conse- 
quence of, or is attended with, evacuations of different 
kinds. A hemorrhagy, sometimes from the right nos- 
tril, and sometimes from the hemorrhoidal vessels, gives 
a solution of the disease. Sometimes a bilious diar- 
rhoea contributes to the same event; and the resolution 
of the hepatitis, as of other inflammations, is attended 
with sweating, and with an evacuation of urine, depo- 
siting a copious sediment. Can this disease be resolv- 
ed by expectoration? It would seem to be sometimes 
cured by an erysipelas appearing in some external part. 

420. When this disease has ended in suppuration, 
the pus collected may be discharged by the biliary 
ducts; or, if the suppurated part does not any where 
adhere closely to the neighbouring parts, the pus may 
be discharged into the cavity of the abdomen; but if, 
during the first state of inflammation, the affected part 
of the liver shall have formed a close adhesion to some 
of the neighbouring parts, the discharge of the pus 
after suppuration may be various, according to the dif- 
ferent seat of the abscess. When seated on the con- 
vex part of the liver, if the adhesion be to the perito- 
naeum lining the common teguments, the pus may 
make its way through these, and be discharged out- 

VOL. I. oo 



290 PRACTICE OF PHYSIC. 

wardly ; or, if the adhesion should have been to the 
diaphragm, the pus may penetrate through this, and into 
the cavity of the thorax, or of the lungs, and through 
the latter may be discharged by coughing. When the 
abscess of the liver is seated on its concave part, then, 
in consequence.of adhesions, the pus may be discharg- 
ed into the stomach or the intestines; and into these 
last, either directly, or by the intervention of the biliary 
ducts. 

421. The prognostics in this disease are established 
upon the general principles relating to inflammation, 
upon the particular circumstances of the liver, and 
upon the particular state of its inflammation. 

The cure of this disease must proceed upon the ge- 
neral plan ; by bleeding, more or less, according to the 
urgency of pain and pyrexia; by the application of 
blisters; by fomentations, of the external parts in the 
usual manner, and of the internal parts by frequent 
emollient glysters; by frequently opening the belly, by 
means of gentle laxatives, and by diluent and refrige- 
rant remedies. 

4>22. Although, in many cases, the chronic hepatitis 
does not clearly discover itself; yet upon many occa- 
sions it may perhaps be discovered, or at least suspect- 
ed from those causes which might affect the liver (316.) 
having been applied; from some fulness and some sense 
of weight in the right hypochondrium; from some shoot- 
ing pains at times felt in that region; from some unea- 
siness or pain felt upon pressure in that part; from some 
uneasiness from lying upon the left side; and lastly, 
from some degree of pyrexia, combined with more or 
fewer of these symptoms. When, from some of these 
circumstances, a chronic inflammation is to be suspect- 
ed, it is to be treated by the same remedies as in the 



PRACTICE OF PHYSIC. ^91 

last paragraph, employed more or less, as the degree 
of the several symptoms shall more distinctly indicate. 

423. When from either kind of inflammation, a sup- 
puration of the liver has been formed, and the abscess 
points outwardly, the part must be opened, the pus eva- 
cuated, and the ulcer healed according to the ordinary 
rules for cleansing and healing such abscesses and ulcers. 

424. I might here consider the Splenitis, or inflam- 
mation of the spleen; but it does not seem necessary, 
because the disease very seldom occurs. When it does, 
it may be readily known by the character given in our 
Nosology: and its various termination, as well as the 
practice which it requires, may be understood from what 
has been already said with respect to the inflammations 
of the other abdominal viscera. 



CHAPTER XI. 



OF THE NEPHRITIS, OR THE INFLAMMATION OF 
THE KIDNEYS. 

425. THIS disease, like other internal inflammations, 
is always attended with pyrexia ; and is especially known 
from the region of the kidney being affected with pain, 
commonly obtuse, sometimes pungent. This pain is not 
increased by the motion of the trunk of the body, so 
much as a pain of the rheumatic kind affecting the same 
region. The pain of the nephritis may be often dis- 
tinguished by its shooting along the course of the ureter; 
and is frequently attended with a drawing up of the 
testicle, and with a numbness of the limb on the side 
affected; although, indeed, these symptoms most com- 
monly accompany the inflammation arising from a cal- 
culus in the kidney, or in the ureter. The nephritis is 



292 PRACTICE OF PHYSIC. 

almost constantly attended with frequent vomiting, and 
often with costiveness and colic pains. Usually the state 
of the urine is changed; it is most commonly of a deep 
red colour, is voided frequently, and in small quantity 
at a time. In more violent cases the urine is sometimes 
colourless. 

426. The remote causes of this disease may be vari- 
ous; as, external contusion; violent or long continued 
riding: strains-of the muscles of the back incumbent on 
the kidneys; various acrids in the course of the circula- 
tion, conveyed to the kidneys; and perhaps some other 
internal causes not yet well known. The most frequent 
is that of calculous matter obstructing the tubuli, urini- 
feri, or calculi formed in the pelvis of the kidneys, and 
either sticking there, or fallen into the ureter. • 

421. The various event of this disease may be under- 
stood from what has been delivered on the subject of 
other inflammatfons. 

428. Writers, in treating of the cure of the nephritis, 
have commonly at the same time treated of the cure of 
the calculis renalis; but, though this may often produce 
nephritis, it is to be considered as a distinct and sepa- 
rate disease ; and what I have to offer as to the mode of 
treating it, must be reserved to its proper place. Here I 
shall treat only of the cure of the Mephritis Vera or 
Idiopathica. 

429. The cure of this proceeds upon the general 
plan, by bleeding, external fomentation, frequent emol- 
lient glysters, antiphlogistic purgatives, and the free 
use of mild and demulcent liquids. The application of 
blisters is hardly admissible; or, at least, will require 
great care, to avoid any considerable absorption of the 
cantharides.* 

* In addition to venesection, recommended by our author, which must be 
pushed, at times, to a considerable extent, copious topical blood-letting 



PRACTICE OF PHYSIC. 293 

430. The Cystitis, or inflammation of the bladder, is 
seldom a primary disease; and therefore is not to be 
treated of here. The treatment of it, so far as necessary 

from the region of the kidneys, by cups or leeches, is an important remedy 
in Nephritis, and should by no means be omitted. It may be repeated, 
with advantage, should the continuance of fever, and the obstinacy and 
severity of the pain require it. 

The professor's fears, in relation to the absorption of cantharides in case 
of blistering, are totally unfounded. Cantharides are not absorbed; and the 
affection of the urinary organs, under these circumstances, is entirely sympa- 
thetic. Besides, it is not in the kidneys, but in the bladder, that the irrita- 
tion is produced. We do not, therefore, perceive how it can be injurious in 
the treatment of Nephritis : nor have we, from experience, ever found it so. 
On the other hand, we think blistering on the lumbar region, in this com- 
plaint, not only an admissible but a useful remedy ; the more so, in as much 
a^ the irritation produced on the neck of the bladder may lessen that in the 
kidneys through the medium of sympathy. If the primary irritation, by a 
blister on the skin, be useful in removing an internal topical affection, why 
not the secondary one on the neck of the bladder? Whether our reasoning 
on this head be, in all points, conclusive or not, we are persuaded that 
blistering at the proper period of Nephritis is not hurtful. It is considered 
so, not from observation, but on principles of hypothesis. 

In addition to the plan of treatment, enjoined by our author, in this dis- 
ease, viz. the antiphlogistic regimen generally, bleeding, purging by glys- 
ters, and the copious use of demulcent drinks, we can recommend, from 
experience, lying on a mattress instead of a feather bed, and the employ- 
ment of mercury. The former of these prevents the accumulation of undue 
warmth around the region of the kidneys, and the latter we have found to 
be a most important remedy, when carried to the extent of a gentle saliva- 
tion. To this we have known a nephritic affection immediately to give way, 
after it had resisted every other remedy that is usually employed. As in 
most other cases of disease, the preparation of mercury we have commonly 
made use of is calomel, given to the amount of three or four grains per day. 
Nor have we hesitated for a moment to add to each dose of calomel ten or 
twelve grains of nitre : convinced that that neutral salt is not only safe but 
useful. It acts primarily on the stomach, and by sympathy on the kidneys ; 
and produces, as we feel persuaded, on these latter organs, no injurious 
irritation by making its way into the serum of the blood. 

Warm fomentations extensively applied on the lumbar region, seldom fail 
to give relief in this disease. If practicable to employ them, therefore, they 
should never be neglected. Great care, however, must be taken, lest, by 
exposure to cold immediately afterwards, or at the time, the patient expe- 
rience a chill. 

As the sickness at stomach, which usually, or at least very often, accom- 
panies this disease, reduces by sympathy the action of the arteries, without 
actually relieving the existing inflammation, the pulse cannot be very confi- 
dently relied on as an index to blood-letting. The appearance of the blood 



294 PRACTICE OF PHYSIC. 

to be explained, may be readily understood from what 
has been already delivered. 

431. Of the visceral inilammations there remains to 
be considered the inflammation of the Uterus; but I 
omit it here, because the consideration of it cannot be 
separated from that of the diseases of child-bearing wo- 
men. 

already drawn, and the degree of pain that may still continue, must be care- 
fully attended to in settling the indication. 

Respecting the diseases of Cystitis and Hysteritis, which our author refers 
to in this chapter, we think it necessary to observe, that, in their treatment, 
they require blood-letting, for the most part to very great extent. 

The reason of this we think sufficiently obvious. The bladder and ute- 
rus, being detached organs, are supplied with blood by arteries of inferior 
size. They cannot, therefore, feel the effect of each act of venesection in 
the same degree as if their arteries were larger. To. bleed from the arm 
in these complaints is somewhat as it would be to open the same vein in a 
case of whitlow. The part inflamed is but little affected by it. It is hence 
that the operation must be frequently repeated, until the action of the arte- 
ries is very much reduced. 

Could topical blood-letting be practised on the parts affected, it would 
prove a much more efficacious remedy. Cups and leeches applied exter- 
nally in the region of these parts, and also in the groins, are found to be 
useful. The quantity of blood taken away by them ought to be copious. 
But, for general blood-letting, although not so efficacious here as we could 
wish it to be, nothing can operate as a substitute. 

Puking is said to be a more useful remedy in these diseases, especially in 
Hysteritis, than in any other of the phlegmasia. From the direct and pow- 
erful sympathy that exists between the stomach and uterus, were are not 
much inclined to a disbelief of the fact. Our own experience, however, 
does not authorize us to decide on the subject. We consider the remedy 
worth a trial. 

In Hysteritis, and Cystitis in females, what would be the effect of the in- 
troduction of ice, or the frequent injection of cold water into the vagina ? 

In the treatment of cystitis in males, the application of ice to the peri- 
neum and external organs of generation has been found useful. A copious 
extraction of blood from the perineum by means of leeches, may be also 
practised with advantage. Bleeding from the hemorrhoidal vessels is also 
said to afford relief. These several remedies seem founded in reason. 



PRACTICE OF PHYSIC. 295 

CHAPTER XII. 
OF THE RHEUMATISM.* 

432. OF this disease there are two species, the one 
named the Acute, the other the Chronic rheumatism. 

* Our author's history and description of this disease, as well as his expo- 
sition of the principles of practice in it, are ample and excellent. We know 
but few pieces of medical composition richer in matter that is worth remem- 
bering. On the attention of students of medicine, therefore, it has the 
strongest of claims. It will instruct them in the knowledge of an important 
disease. 

The hereditary nature of Rheumatism constitutes a feature in the charac- 
ter of that complaint, which we do not recollect to have seen any where re- 
presented. Yet that it possesses such a feature, does not, we think, admit 
of a doubt. 

It is indeed true, that if exposed for a sufficient length of time to its excit- 
ing causes, most persons will be ultimately attacked by rheumatism. But it is 
no less true, that some of these will suffer from it much sooner, and more 
readily and certainly, than others; not because they have weaker systems; 
but because they are constitutionally predisposed to the disease ; because 
they possess an organization or structure of parts peculiarly susceptible of 
the morbid action wherein it consists. 

To dwell, for, a moment, on this point, will be neither, we trust, useless 
nor uninteresting. 

Pulmonary consumption is a disease of the lungs, and is known to attack 
such children or descendants, as resemble, particularly in the form and struc- 
ture of the chest, their parents or ancestors who had been previously sub- 
ject to it. Hence it is considered a hereditary complaint. 

Madness is a disease of the brain, and is communicated from parents to 
their children, along with a similarity of countenance and person. It is, in 
like manner, therefore, called hereditary. 

Gout passes also most readily to those descendants who most resemble 
such of their ancestors as had previously suffered from it. Our author, there- 
fore, himself embraces, in his definition of it, its hereditary quality. 

Rheumatism is a disease of the joints, prevails in some families much more 
than in others; and, in these cases, attacks with most certainty those chil- 
dren, who, in personal appearance, most strongly resemble such of their 
ancestors as had been already subject to it. Why, then, is not it also re- 
garded as hereditary ? Is a disease passing from parent to child, in conse- 
quence of a similarity of brain and lungs, to be denominated hereditary ? and 
shall the same title be denied to one that passes, in the same way, by means 



296 PRACTICE OF PHYSIC. 

433. It is the acute rheumatism which especially be- 
longs to this place, as from its causes, symptoms, and 
methods of cure, it will appear to be a species of phleg- 
masia, or inflammation. 

434. This disease is frequent in cold, and more un- 
common in warm climates. It appears most frequently 
in autumn and spring, less frequently in winter when the 
cold is considerable and constant, and very seldom dur- 
ing the heat of summer. It may occur, however, at any 
season, if vicissitudes of heat and cold be for the time 
frequent. 

435. The acute rheumatism generally arises from the 
application of cold to the body when anyway unusually 
warm ; or when any part of the body is exposed to cold 
whilst the other parts are kept warm ; or, lastly, when 
the application of the cold is long continued, as it is 
when wet or moist clothes are applied to any part of the 
body. 

436. These causes may affect persons of all ages; but 
the rheumatism seldom appears in either very young or 
in elderly persons, and most commonly occurs from the 
age of puberty to that of thirty-five years.* 

437. These causes (435.) may also affect persons of 
any constitution; but they most commonly affect those of 
a sanguine temperament. 

438. This disease is particularly distinguished by 
pains affecting the joints, for the most part the joints 
alone, but sometimes affecting also the muscular parts. 

of a similarity of joints and muscles? Re custom and fashion what they may, 
we can perceive in nature no reason why this should be the case. It would 
not, we think, be difficult to show, that there exists scarcely an argument in 
proof of the hereditary nature of gout, which may not be urged with equal 
pertinency in favour also of that of Rheumatism. 

* We have seen not only children, but also persons far advanced in years, 
labouring under very severe attacks of acute rheumatism. Chronic rheuma- 
tism is known to be particularly incidental to the aged. It too often consti- 
tutes one of the miseries of the evening of life. 



PRACTICE OF PHYSIC. 291 

Very often the pains shoot along the course of the mus- 
cles, from one joint to another, and are always much in- 
creased by the action of the muscles belonging to the 
joint or joints affected. 

439. The larger joints are most frequently affected, 
such as the hip-joint and knees of the lower, and the 
shoulders and elbows of the upper extremities. The 
ankles and wrists are also frequently affected; but the 
smaller joints, such as those of the toes or fingers, sel 
dom suffer. 

440. This disease, although sometimes confined to 
one part of the body only, yet very often affects many 
parts of it; and then it comes on with a cold stage, 
which is immediately succeeded by the other symptoms 
of pyrexia, and particularly by a frequent, full, and hard 
pulse. Sometimes the pyrexia is formed before any 
pains are perceived; but more commonly pains are felt 
in particular parts, before any symptoms of pyrexia ap- 
pear.* 

441. When no pyrexia is present, the pain is some- 
times confined to one joint only; but, when any consi- 
derable pyrexia is present, although the pain may be 
chiefly in one joint, yet it seldom happens but that the 
pains affect several joints often at the very same time, 
but for the most part shifting their place, and having 
abated in one joint, become more violent in another. 
They do not commonly remain long in the same joint, 
but frequently shift from one to another, and sometimes 
return to joints formerly affected; and in this manner 
the disease often continues for a long time, 

442. The pyrexia attending this disease has an ex- 

* In this, as in all other general diseases, pyrexia arises from a local affec- 
tion. It very rarely, therefore, precedes pain, and never irritation.- and we 
have stated, on a former occasion, that a mere irritative affection is as capa- 
ble of giving rise to general fever as a sensitive one. 
VOL. I. p p 



22$ PRACTICE OF PHYSIC. 

acerbation every evening, and is most considerable dur- 
ing the night, when the pains also become more violent; 
and it is at the same time that the pains shift their place 
from one joint to another. The pains seem to be also 
increased during the night, by the body being covered 
more closely, and kept warmer. 

443. A joint, after having been for some time affected 
with pain, commonly becomes affected also with some 
redness and swelling, which is painful to the touch. It 
seldom happens, that a swelling coming on does not alle- 
viate the. pain of the joint; but. the swelling does not 
always take off the pain entirely, nor secure the joint 
against a return of it.* 

444. This disease is commonly attended with some 
sweating, which occurs early in the course of the dis- 
ease; but it is seldom free or copious, and seldom either 
relieves the pains or proves critical. 

445. In the course of this disease the urine is high- 
coloured, and in the beginning without sediment; but as 
the disease advances, and the pyrexia has more consider- 
able remissions, the urine deposits a lateritious sedi- 
ment. This, however, does not prove entirely critical: 
for the disease often continues long after such a sedi- 
ment has appeared in the urine. 

446. When blood is drawn in this disease, it always 
exhibits the appearance mentioned (237.) 

447. The acute rheumatism, though it has so much 
of the nature of the other phlegmasia?, differs from all 
those hitherto mentioned, in this, that it is not apt to 
terminate in suppuration. This almost never happens 

* In rheumatism the inflammation is primarily membranous. The swell- 
ing that occurs is produced bv an effusion from the diseased and distended 
vessels into the cellular substance by which they are surrounded. This ef- 
fusion operates like a topical evacuation from the inflamed part, takes off 
the tension from the labouring vessels, and, in this way, mitigates the seve- 
rity of the pain. 



PRACTICE OF PHYSIC. 299 

in rheumatism; but the disease sometimes produces effu- 
sions of a transparent gelatinous fluid into the sheaths 
of the tendons. If we may be allowed to suppose that 
such effusions are frequent, it must also happen, that 
the effused fluid is commonly reabsorbed; for it has 
seldom happened, and never indeed to my observation, 
that considerable or permanent tumours have been 
produced, or such as required to be opened, and to 
have the contained fluid evacuated. Such tumours, 
however, have occurred to others, and the opening made 
.in them has produced ulcers difficult to heal. Vide 
Storck. Ann. Med. II.* 

448. With the circumstances mentioned from (438. 
to 447.) the disease often continues for several weeks. 
It seldom, however, proves fatal: and it rarely happens 
that the pyrexia continues to be considerable for more 
than two or three weeks. While the pyrexia abates in 
its violence, if the pains of the joints continue, they are 
less violent, more limited in their place, being confined 
commonly to one or a few joints only, and are less ready 
to change their place. 

449. When the pyrexia attending rheumatism has 
entirely ceased; when the swelling, and particularly the 
redness of the joints, are entirely gone; but when pains 
still continue to affect certain joints, which remain stiff, 
which feel uneasy upon motion, or upon changes of 
weather; the disease is named the Chronic Rheumatism, 
as it very often continues for a long time. As the chro- 
nic is commonly the sequel of the acute rheumatism, 

* The inflammation in rheumatism is as much of a nature sui generis — as 
specifically different from every other kind of inflammation, as is that of 
■mall pox, kine pox or lues venerea. The difference of the diseased action 
is conclusively manifested by the difference of its results, — rheumatic inflam- 
mation, strictly so called, often, like that of gout, suddenly shifting from 
place to place, and never terminating in suppuration or gangrene. When 
it terminates in either, it is of a spurious kind. 



300 PRACTICE OF PHYSIC. 

I think it proper to treat of the former also in this 
place.* 

450. The limits between the acute and chronic rheu- 
matism are not always exactly marked. 

When the pains are still ready to shift their place; 
when they are especially severe in the night-time; when, 
at the same time, they are attended with some degree of 
pyrexia, and with some swelling, and especially with 
some redness of the joints; the disease is to be consi- 
dered as still partaking the nature of the acute rheu- 
matism. 

But when there is no degree of pyrexia remaining; 
when the pained joints are without redness; when they 
are cold and stiff; when they cannot easily be made to 
sweat; or when while a free and warm sweat is brought 
out on the rest of the body, it is only clammy and cold 
on the pained joints; and when especially, the pains of 
these joints are increased by cold, and relieved by heat 
applied to them; the case is to be considered as that of 
a purely chronic rheumatism.f 

451. The chronic rheumatism may affect different 
joints; but is especially ready to affect those joints which 
are surrounded with many muscles, and those of which 
the muscles are employed in the most constant and vi- 
gorous exertions. Such is the case of the vertebrae of 
the loins, the affection of which is named Lumbago; or 
that of the hip-joint, when the disease is named Ischias, 
or Sciatica. 



* We believe that in youthful persons, and even in those who have not 
yet attained their forty-fifth year, the acute rheumatism, if properly treated, 
never terminates in the chronic. Such a termination must be the result of 
neglect or unskilful practice. Chronic rheumatism, induced under these 
circumstances, can be nothing but an acute form of the disease imperfectly 
cured- 

f In this paragraph is drawn with a nice and masterly hand the line of dis- 
crimination between acute and chronic rheumatism. 



PRACTICE OF PHYSIC. 301 

452. Violent strains and spasms occurring on sudden 
and somewhat violent exertions, bring on rheumatic 
affections, which at first partake of the acute, but very 
soon change into the nature of the chronic rheumatism. 

453. I have thus delivered the history of rheuma- 
tism; and suppose, that, from what has been said, the 
remote causes, the diagnosis, and prognosis of the dis- 
ease, may be understood. The distinction of the rheu- 
matic pains from those resembling them, which occur 
in the syphilis and scurvy, will be obvious, either from 
the seat of those pains, or from the concomitant symp- 
toms peculiar to these diseases. The distinctions of 
rheumatism from gout will be more fully understood 
from what is to be delivered in the following chapter.* 

454. With respect to the proximate cause of rheu- 
matism, there have been various opinions. It has been 
imputed to a peculiar acrimony ; of which, however, in 
ordinary cases, I can find no evidence; and from the 
consideration of the remote causes, the symptoms and 
cure of the disease, I think the supposition very im- 
probable. 

The cause of an Ischias Nervosa assigned by Co- 
tunnius, appears to me hypothetical, and is not sup- 
ported by either the phenomena or method of cure. 
That, however, a disease of a rheumatic nature may be 
occasioned by an acrid matter applied to the nerves, is 
evident from the tooth-ach, a rheumatic affection gene- 
rally arising from a carious tooth. 

That pains resembling those of rheumatism may 
arise from deep-seated suppurations, we know from 

* Notwithstanding all our author has here said, there occurs, at times, no 
inconsiderable difficulty in distinguishing pains of a purely rheumatic charac- 
ter from those connected with lues venerea, and perhaps also with scurvy. 
To enable himself fairly to make up his mind on this subject, the physician 
is often obliged to inquire very minutely into the previous history, habits 
and practices of his patient. 



302 PRACTICE OF PHYSIC. 

some cases depending on such a cause, and which, in 
tlnir symptoms, resemble the lumbago or ischias. I 
believe, however, that by a proper attention, these cases 
depending on suppuration, may be commonly distin- 
guished from the genuine cases of lumbago and ischias; 
and from what is said in (447.) I judge it to be at least 
improbable, that a genuine lumbago or ischias does ever 
end in suppuration. 

455. The proximate cause of rheumatism has been 
by many supposed to be a lentor of the fluids obstruct- 
ing the vessels of the part; but the same consideration 
as in (241. 1, 2, 3, 4, and 5.) will apply equally here 
for rejecting the supposition of a lentor. 

456. While I cannot, therefore, find either evidence 
or reason for supposing that the rheumatism depends 
upon any change in the state of the fluids, I must con- 
clude, that the proximate cause of acute rheumatism, is 
commonly the same with that of other inflammations 
not depending upon a direct stimulus. 

457. In the case of rheumatism, 1 suppose, that the 
most common remote cause of it, thai is, cold applied, 
operates especially on the vessels of the joints, from 
these being less covered by a cellular texture than 
those of the intermediate parts of the limbs. I suppose 
further, that the application of cold p'roduces a con- 
striction of the extreme vessels on the surface, and at 
the same time an increase of tone or phlogistic diathe- 
sis in the course of them, from which arises an increas- 
ed impetus "of the blood, and, at the same time, a re- 
sistance to the free passage of it, and consequently in- 
flammation and pain. Further, I suppose, that the re- 
sistance formed excites the vis medicatrix to a further 
increase of the impetus of the blood; and, to support 
this, a cold stage arises, a spasm is formed, and a py- 



PRACTICE OF PHYSIC. 305 

rexia and phlogistic diathesis are produced in the whole 
system.* 

458. According to this explanation, the cause of 
acute rheumatism appears to be exactly analogous to 
that of the inflammations depending on an increased 
afflux of blood to a part while it is exposed to the ac- 
tion of cold. 

But there seems to be also, in the case of rheuma- 
tism, a peculiar affection of the fibres of the muscles. 

These fibres seem to be under some degree of rigi- 
dity, and therefore less easily admit of motion; and are* 
pained upon the exertions of it. 

It is also an affection of these fibres which gives an 
opportunity to the propagation of pains from one joint 
to another, along the course of the muscles, and which 
pains are more severely felt in the extremities of the 
muscles terminating in the joints, because, beyond 
these, the oscillations are not propagated. 

This affection of the muscular fibres attending rheu- 
matism, seems to explain why strains and spasms pro- 
duce rheumatic affections; and, upon the whole, shows, 
that, with an inflammatory affection of the sanguiferous 
system, there is also in rheumatism a peculiar affection 
of the muscular fibres, which has a considerable share 
in producing the phenomena of the disease.f 

* It will be perceived tliat our author delivers here his usual doctrine of 
the proximate cause of'inflammation, in which is included his belief that the 
blood moves through the inflamed vessels with an increased impetus In 
this, we repeat, he must be mistaken. In every case of genuine inflamma- 
tion there appears to be necessarily, in the diseased vessels, a diminished 
rather than an increased rapidity and force in the movement of the blood. 
This is true in relation to rheumatic inflammation, as well as to that of every 
other kind. 

f This rigidity of the fibres in rheumatism may be owing to a remora in 
the fluids of what we might denominate the vasa fibvarum; or at least to 
some species of disease in these vessels, in consequence of which they do 
not secrete the fine mucus, or rather halitus, requisite to lubricate the parts, 
and to enable them to move with the facility of health. For it is not impre- 



304 PRACTICE OF PHYSIC. 

459. Having thus given my opinion of the proximate 
cause of rheumatism, I proceed to treat of the cure. 

460. Whatever difficulty may occur with respect to 
the explanation given, (457. and 458.) this remains 
certain, that in acute rheumatism, at least in all those 
cases which do not arise from direct stimuli, there is 
an inflammatory affection of the parts, and a phlogistic 
diathesis in the whole system; and upon these is found- 
ed the method of cure, which frequent experience has 
approved of. 

461. The cure therefore requires, in the first place, 
an antiphlogistic regimen, and particularly a total absti- 
nence from animal food, and from all fermented or spi- 
rituous liquors; substituting a vegetable or milk diet, 
and the plentiful use of bland diluent drinks.* 

462. Upon the same principle (449.) at least with 
perhaps the same exception as above, blood-letting is 
the chief remedy of acute rheumatism. The blood 
ought to be drawn in large quantity, and the bleeding 
is to be repeated in proportion to the frequency, ful- 
ness, and hardness of the pulse, and to the violence of 
the pain. For the most part, large and repeated bleed- 
ings during the first days of the disease, seem to be ne- 
cessary, and accordingly have been very much employ- 
ed: but to this some bounds are to be set; for very 
profuse bleedings occasion a slow recovery, and, if not 

bable that each fibre is inclosed in a fine sheath similar to that of the muscle 
to which it belongs, and requiring to be moistened and prepared for mo- 
tion by a liquid secreted specifically for the purpose. Rheumatic inflam- 
mation would seem to be to the vasa fibrarum, what phlegmonic inflamma- 
tion is to the vessels belonging to the cellular membrane. 

* In acute rheumatism accompanied with pyrexia, a milk diet is totally 
inadmissible. Barley water, rice water, currant jelly dissolved in water, 
and other articles, bland and purely vegetable, constitute the only sizable 
diet in this disease. If any part of milk be allowable, it is the whey, pre- 
pared by buttermilk, or some vegetable acid. 



PRACTICE OF PHYSIC. 305 

absolutely effectual, are ready to produce a chronic 
rheumatism* 

463. To avoid that debility of the system, which ge- 
neral bleedings are ready to occasion, the urgent symp- 
tom of pain may be often relieved by topical bleedings; 
and especially when any swelling and redness have come 
upon a joint, the pain of it may be very certainly re- 
lieved by such bleedings; but, as the continuance of the 
disease seems to depend more upon the phlogistic dia- 
thesis of the whole system, than upon the affection of 
particular parts, so topical bleedings will not always 
supply the place of the general bleedings proposed 
above.f 

464. To take off the phlogistic diathesis prevailing in 
this disease, purging may be useful, if procured by me- 
dicines which do not stimulate the whole system, such 
as the neutral salts, and which have, in some measure, 
a refrigerant power. Purging, however, is not so pow- 
erful as bleeding, in removing phlogistic diathesis; and 
when the disease has become general and violent, fre- 
quent stools are inconvenient and even hurtful, by the 
motion and pain which they occasion. J 

* We do not believe that " profuse bleedings" ever have been, or ever 
can be, productive of" chronic rheumatism." As often as the acute is con- 
verted into the chronic form of this disease, it is rather in consequence of a 
deficiency than an excess of blood-letting-. As a liberal loss of blood pre- 
vents peripneumony from terminating in empyema or hydrothorax, catarrh 
in pulmonary consumption, and bilious remitting fever in hepatitis and 
dropsy, so does it prevent the acute from terminating in the chronic form of 
rheumatism. 

j- Copious topical evacuations from the inflamed joints by leeches and 
cups, although not to be resorted to as a substitute for general blood-let- 
ting, is notwithstanding, when judiciously used, an invaluable auxiliary to it. 
When the pain and inflammation, therefore, are great, it should never be 
neglected. 

* In pure rheumatism, we have rarely employed purgatives for any other 
purpose, than to keep the bowels free from irritating contents. If carried 
beyond this, they become inconvenient ; and, as we are inclined to believe, 
do as much injury by the motion which they compel the patient to use, as 

vol. I. q q 



306 PRACTICE OF PHYSIC. 

465. In acute rheumatism, applications to the pained 
parts are of little service. Fomentations, in the beginning 
of the disease, rather aggravate, than relieve the pains. 
The rubefacients and camphire are more effectual in 
relieving the pains; but generally they only shift the pain 
from one part into another, and do little towards the cure 
of the genera! affection. Blistering, applied to the pained 
part, may also be very effectual in removing the pain 
from it; but will be of little use, except where the pains 
are much confined to one part. 

466. The several remedies mentioned from 450. to 
454. moderate the violence of the disease, and some- 
ti es remove it entirely; but they sometimes fail in this, 
and leave the cure imperfect. The attempting a cure by 
large and repeated bleedings, is attended with many in- 
conveniences, (see 140.) and the most effectual and 
safe method of curing this disease, is, after some gene- 
ral bleedings for taking off, or at least diminishing, the 
phlogistic diathesis, to employ sweating, conducted by 
the rules laid down (168. and 169,)* 

they do good by their power of evacuation. In a disease so highly arterial as 
that of rheumatism, and, in the production of which, the first morbific impres- 
sion is usually made on the skin, they can, in no shape, be regarded as a 
substitute fot blood-letting. 

In case of cathartics being used in this disease, for the reduction of arte- 
rial action, the saline purgatives are the most suitable. A solution of 
Glauber's, Epsom, or llochelle salts, in a strong infusion of senna and manna 
constitutes, for this purpose, one of the best preparations. 

* Sweating in rheumatism, provided it be employed at the proper period 
viz. after blood-letting has sufficiently reduced arterial action, is, in general 
a valuable remedy. We have seen it, however, in some instances, very 
fairly and extensively employed, without contributing much to weaken the 
complaint. In such cases, blisters applied to the inflamed joints, after the 
disease had been reduced, by general remedies, to somewhat of a local 
character, were productive of salutary effects. But, blisters do no good— 
they rather prove injurious, if applied while the symptoms of pyrexia are 
high. 

An excellent sweating formula is the nitrous powder combined with calo- 
mel and tarlarized antimony, which v as formerly mentioned. 
The hourly exhibition of a grain or two of ipecacuanha, combined with 



PRACTICE OF PHYSIC. SOI 

467. Opiates, except where they are directed to pro- 
cure sweat, always prove hurtful in every stage of this 
disease. 

468. The Peruvian bark has been supposed a remedy 
in some cases of this disease; but we have seldom found 
it useful, and in some cases hurtful. It appears to me to 
be fit in those cases only, in which the phlogistic dia- 
thesis is already much abated, and where, at the same 
time, the exacerbations of the disease are manifestly 
periodical, with considerable remissions interposed 

469. Calomel and some other preparations of mercury, 
have been recommended in the acute rheumatism; but I 
believe they are useful only in cases of the chronic kind, 
or at least in cases approaching to the nature of these. 

470. Having now treated fully of the cure of the 
acute rheumatism, I proceed to treat of the cure of the 
chronic, which is so frequently a sequel of the former. 

471. The phenomena of the purely chronic rheuma- 
tism, mentioned in 438. and 439. lead me to conclude, 
that its proximate cause is an atony, both of the blood- 
vessels and of the muscular fibres of the p rt affected, 
together with a degree of rigidity and contraction in the 
latter, such as frequently attends them in a state of atony. 

472. Upon this view of the proximate cause the gen j- 
ral indication of cure must be, to restore the activity 
and vigour of the vital principle in the part; and the re- 
medies for this disease, whi I) experience has approved 
of, are chiefly such as are manifestly suited to the indi- 
cation proposed. 

ten or twelve grains of nitre, warm diluting drinks being given in the interim, 
constitutes an excellent sudorific process. To this, to prevent sickness and 
purging, we have sometimes advantageously added, from the sixth to the 
tenth of a grain of opium. Heating sudorifics should be carefully avoided. 
If the disease prove obstinate, the calomel and nitre may be very properly 
continued until the gums become affected with the mercurial action. On 
the occurrence of this, the symptoms of the complaint almost always give 
way. 



308 PRACTICE OF PHYSIC. 

473. These remedies are either external or internal. 
The external are, the supporting the heat of the part, 

by keeping it constantly covered with flannel; the in- 
creasing the heat of the part by external heat, applied 
either in a dry or in a humid form; the diligent use of 
the flesh-brush, or other means of friction; the applica- 
tion of electricity in sparks or shocks; the application of 
cold water by affusion or immersion ; the application of 
essential oils of the most warm and penetrating kind; 
the application of salt brine; and lastly, the employment 
of exercise, either of the part itself so far as it can 
easily bear it, or of the whole body by riding, or other 
mode of gestation.* 

474. Tho internal remedies are, 1. Large doses of es- 

* To prove permanently useful, the electric fluid should be administered 
in a much more continued form ; *. e. more frequently, and longer each 
time, than is usually the case. If the patient be placed under its influence, 
only from half an hour to an hour, each day, he will derive from it but little 
advantage. So true is it, that a chronic disease can be removed only by a 
chronic remedy. 

Cold water applied : n the form of the shower-bath, if it does not produce 
chilliness, but is succeeded by a pleasant glow on the surface of the body, 
has been found very useful in chronic rheumatism. It gives tone to the skin, 
hence to the stomach, and hence again to the whole system. 

Bandaging the affected limb or part equably, but somewhat tightly, with 
flannel rollers, proves exceedingly useful in the treatment of this disease. 
It gives support to the muscles of the part, aids circulation in them, prevents 
in them the sensation of fatigue, and thus restores to them their lost tone. 
It produces, in fact, a new impression, whence proceeds a new action, which 
effectually severs the morbid assopiation, wherein the disease consists. It 
also aids in promoting perspiration. 

As far as we are informed on the subject, this remedy was first used in 
this city by the present professor of the theory and practice of physic in the 
university of Pennsylvania. 

When we come to speak of certain chronic affections of the bowels we 
shall say that a similar remedy has been found extremely useful in their 
treatment. 

On the operation of the Juniperus Sabina, or Savin, in chronic rheuma- 
tism, we are permitted, by the kindness of Dr. Chapman, to take from his 
manuscript lectures, the following interesting and important extract : 

" The Savin, in its operation on the system, produces the effects of a 
warm, powerful, and diffusible stimulant, exciting all the secretions, with a 
considerable determination to the surface. 



PRACTICE OF PHYSIC. 309 

sential oil drawn from resinous substances, such as tur- 
pentine; 2. Substances containing such oils, as guaiac; 

" Baffled in my attempts to cure some of the forms of chronic rheuma- 
tism with the ordinary remedies, it is now upwards of five years, since I was 
led, in consequence of my speculative notions, as to the powers of this me- 
dicine, to experiment with it in this disease. During the period which has 
subsequently elapsed, I have prescribed it very extensively, both in public 
and private practice. The result of my numerous trials with it is such, that 
I hope it will not be deemed the language of enthusiasm, when I declare, 
that 1 hold it to be entitled to be placed at the very head of the remedies in 
chronic rheumatism. 

" But, for its successful application, it requires a very nice discrimination 
in the selection of the proper cases. 

" My enlarged experience with the medicine, has taught me some degree 
of certainty in its use. It is still, however, not easy, by any general descrip- 
tion, to impart the same sort of tact, or knowledge." 

After a description of a form of rheumatism, in which there exists great 
exhaustion of the system, with an unusual degree of coldness, and want of 
action on the surface of the body, the professor subjoins the following prac- 
tical remarks : 

" Endued with properties, such as I have alleged it to possess, it was rea- 
sonable to presume that the Savin would prove eminently serviceable in the 
precise form of rheumatism which has been here described. 

" The primary effects of the medicine, or, at least, its sensible effects, are, 
to heat and stimulate the whole system, producing particularly a glow on 
the surface, with much itching, and, ultimately, a slight perspiration, which, 
however, seems to be extorted by the mere force of excitement. There are, 
also, sometimes, miliary eruptions. 

"The influence of the Savin over the circulation is prodigious. The 
pulse, which, previously to its exhibition, is commonly small, weak, and ac- 
celerated, now becomes full, active, and comparatively slow. No portion of 
the system, indeed, seems to escape its wide pervading operation ; every 
function being more or less invigorated, and especially some of the secretory 
offices, as the urinary, the catamenial, and, perhaps, the seminal. 

" Contrary to a very uniform law of the animal economy, by which it 
seems to be ordained that the vigour of the arterial and lymphatic apparatus 
should be in an inverse ratio, we have here indisputable evidence, in the 
speedy removal of the chalky depositions, and of the various morbid growths 
incident to the disease, of absorption being actively performed. 

" After some days' continuance of the Savin, either from the mitigation of 
the disease, or the positive tonic power which the medicine exerts, the situa- 
tion of the patient is very considerably improved, as relates to his strength, 
appetite, rest, and general sensations." 

Encouraged by his successful use of Savin in one kind of chronic rheu- 
matism, Dr. Chapman was led to administer it in another— that which is 
usually denominated syphilitic. Here, again, his success was highly flatter- 
ing; the disease being always alleviated, if not cured, by the remedy. 



310 PRACTICE OF PHYSIC. 

3. Volatile alkaline salts; 4. These, or other medicines 
directed to procure sweat; (169.) and, lastly, calomel, or 
other preparation of mercury, in small doses, continued 
for some time. 

On commencing the use of the Savin, in any case, the professor's practice 
is, to administer to an adult from twelve to fifteen grains of the powdered 
leaves, three times a-day. This dose he gradually increases, until an evident 
effect is produced ; which sometimes, as he informs us, requires " three or 
four times the quantity" with which he had begun. 

In the treatment of chronic rheumatism, much good may be done by 
clothing and exercise 

The patient should wear, constantly, an entire covering of flannel, or fleecy 
hosiery, next to the skin; and, if he be free from fever, take, during fine 
weather, as much exercise in the open air, as he is able to bear without fa- 
tigue. If he even exercise to such an extent as to produce a perspiration, 
so much the better ; provided he be careful not to suffer himself to cool too 
suddenly, or in a partial manner. 

In addition to those already mentioned, many other remedies, both exter- 
nal and internal, may be recommended as useful in chronic rheumatism. 

Of the internal remedies, we may briefly enumerate the following : 

Bruised Mustard-seed. — Of this, a table-spoonful may be taken at a dose, 
and repeated twice or three times a-day. 

Gum Guaiacum, in substance, or tincture. — Of the gum in powder, the dose 
is from a scruple to half a drachm, to be taken from once to three times 
a-day, according as the stomach and bowels may bear it. Of the tincture, 
the volatile being preferable to the simple, a tea-spoonful may be taken 
three or four times a-day. This Temedy proves most useful when it ope- 
rates moderately on the bowels. 

Sarsaparilla. — Of this, a drachm of the extract, or a decoction of half an 
ounce of the root, may be taken at a dose, and repeated as often as circum- 
stances may require. It is deemed valuable as a sudorific, and, therefore, 
throws excitement on the skin. 

Oxyde of Arsenic. — This article may be given either in powder or solu- 
tion. Of the former, the dose may be from the eighth to the sixteenth of a 
grain, and, of the latter, from six to eight, or ten drops, to be repeated, in 
either case, four or five times a-day. This is a very powerful remedy, and 
possesses strong anti rheumatic qualities. 

Peruvian Bark. — This remedy, in common doses, either alone, or in com- 
bination with Virginia snake-root, or gum guaiacum, and repeated seve- 
ral times a-day, has acquired, with some practitioners, considerable reputa- 
tion. 

Mercury. — This, to prove effectual, should be administered in the usual 
doses, until a gentle ptyalism be produced ; which, if the disease be of long 
standing, ought to be continued for a considerable time. 

Opium, given in iari^e and repeated doses, is said to have removed chro- 
nic rheumatism in a few days. Combined with other articles, we have often 
exhibited it in this complaint, with very pleasant and salutary effects. 



PRACTICE OF PHYSIC. 31 1 

475. These (462, 463.) are the remedies successfully 
employed in the purely chronic rheumatism; and there 
are still others recommended, as bleeding, general and 
topical, burning, blistering, and issues: but these ap- 
pear to me. to be chiefly, perhaps only, useful when 
the disease still partakes of the nature of acute rheu- 
matism. 



An indigenous remedy, of considerable reputation, is the juice of the 
berry of the Phytolacca decandria. Of (his, a small wine-glassful may be 
taken two or three times a-day. Although our own experience in this pre- 
paration has not been very extensive, we believe it to be an article of some 
efficacy. To prevent the juice from fermenting and becoming sour, it should 
be mixed, when expressed, with a little spirits of wine, or common brandy. 

In addition to those already mentioned, the external remedies most in use, 
and in highest estimation, are the warm, water or vapour bath, frictions with 
the flesh-brush, or with some spirituous stimulating preparation, such as 
camphorated, or volatile liniment, and cupping, sinapisms, blisters, or setons, 
as near as convenient to the parts affected. 

Tartarized Antimony, moistened with simple water, and briskly rubbed 
with the hand on the diseased part, produces, after a few applications, which 
should be made twice or thrice a-day, a crop of pustules of a peculiar ap- 
pearance and character, and rarely fails to give great relief. 

When other remedies have failed, travelling and change of climate, par- 
ticularly a removal from a colder to a warmer climate, have effected a cure. 
So has a change of life from a more sedentary to a more active. 

A former resident of Philadelphia, with whom we are well acquainted, has 
been, of late, entirely relieved from chronic rheumatism, by exchanging the 
occupation of a manufacturer for that of a farmer. His habits, which, dur- 
ing his first pursuit, were sedentary, are now active, and sometimes laborious. 

In chronic rheumatism, the diet should be nutritive, but not heating. Vi- 
nous and distilled liquors should be used very sparingly. In every instance 
where the physical powers of the system are weakened, perfect temperance, 
a mild climate, pure air, and moderate exercise, are the best restoratives. 



.312 PRACTICE OF PHYSIC. 

CHAPTER XIII. 
OF THE TOOTHACH, OR ODONTALGIA.* 

176. I HAVE formerly considered this disease as a 
species of rheumatism, to be treated upon the same 
principles as those delivered in the preceding chapter; 

* On the subject of Odontalgia, we have but little to say ; our professional 
experience in it being exceedingly limited. 

"We are persuaded, however that Dr. Cullen is entirely mistaken respect- 
ing its theory. It is in no way dependent on an acrimony of the humours. 
Toothach, as a disease, is much more intimately connected with the stomach 
than is generally imagined. 

In corroboration of this, there is an abundance of evidence, accessible to 
every one who may be inclined to go in quest of it. 

The state of the teeth depends very essentially on that of the gums. If 
the latter be in any measure diseased, it is almost impossible for the former 
to be sound. But the condition of the gums is known to be materially in- 
fluenced by that of the stomach. Although a sound state of the stomach 
does not absolutely insure sound gums, because the latter organs may, like 
other parts, be locally affected, yet, during a long continued disease of the 
stomach, the gums rarely escape without injury. Hence it is, that dyspeptic 
persons, and those who are subject to habitual costiveness, suffer so gene- 
rally from carious teeth. Hence, also, the frequency of toothach in 
pregnant and hysterical women, whose stomachs are almost constantly the 
seat of disease. 

The connexion between the teeth and the alimentary canal is very strik- 
ingly manifested during the dentition of children. The diseases induced 
in the stomach and bowels by that process, are known and acknowledged 
by every physician. But the influence, it is reasonable to believe, is reci- 
procal. If a diseased condition of the gums can disorder the primae viae, we 
can have no ground to doubt of the reverse being true — the former must 
sympathize with the sufferings of the latter. 

Even in adults, we have known several instances wherein dyspeptic af- 
fections remained intractable, until after the extraction of carious teeth; 
when they suddenly disappeared without farther remedies. 

The disease, Odontalgia, belongs to the class Neuroses, rather than to 
that of pyrexiae ; it being very seldom accompanied with any febrile action. 
But we feel persuaded, that when the science of pathology shall be better 
understood, the stornach and alimentary canal will be acknowledged to be 
the seat of that whole tribe of diseases, that are now called nervous. Per- 
haps even their name will be ultimately changed, and they will be known 



PRACTICE OF PHYSIC. 313 

but now, from more attentive consideration, I am led to 
consider the toothach as a distinct disease. Whilst the 
most of what has been delivered in the last chapter pro- 
ceeds upon the supposition that the rheumatism depends 
upon a certain state of the blood-vessels, and of the mo- 
tion of the blood in them, without this being produced 
by the irritation of any acrid matter applied; I judge, 
that in the toothach, though there are often the same 
circumstances in the state of the blood-vessels as in the 
cases of rheumatism, these circumstances in toothach 
always arise from the application of an acrid matter to 
the nerves of the teeth. 

477. This disease is often no other than a pain felt in 
a particular tooth, without any inflammatory affection 
being at the same time communicated to the neighbour- 
ing parts. This, however, is rarely the case ; and, for 
the most part, together with the pain of the tooth, there 
is some degree of pain and of inflammatory affection 
communicated to the neighbouring parts, sometimes to 

only by that of diseases of the prima viae. That toothach is a nervous disease, 
appears from the fact, that it is oftentimes cured by the sight of the dentist ; 
or by any other occurrence that produces a fright. 

Women are much more subject than men to complaints of the stomacli 
and bowels. So are they also to odontalgia and carious teeth. This would 
seem to indicate a connexion between these two seats of disease. 

Emetics, given for other purposes, have been known to afford great and 
unexpected relief in the toothach. Without having ourselves ever tried 
the experiment, we are inclined to believe that this would be very often, if 
not generally, the case. The operation of an emetic would seldom fail to 
cure, for the time, a fit of the toothach. 

Such are the principal reasons, occurring to us, at present, which incline 
us to believe that odontalgia is connected with a diseased stomach. In ad- 
dition, then, to perfect cleanliness of the mouth, let those who wish to pre- 
serve their teeth, be active in their endeavours to preserve a sound condi- 
tion of the alimentary canal. 

A diet of unripe and acid fruit, or of crude vegetable substances of any 
other description, is injurious to the teeth. This effect it probably pro- 
duces, much more through the medium of the stomach, than by its direct 
action on the teeth themselves. 

vol, i. r r 



314 PRACTICE OF PHYSIC. 

the whole of those on the same side of the head with 
the affected tooth. 

478. This inflammatory affection seems to me to be 
always an affection of the muscles and of the membran- 
ous parts connected with these, without any tendency 
to suppuration; and such an affection, as is excited by 
cold in similar parts elsewhere. It is from these cir- 
cumstances that l conclude the affection to be of the 
rheumatic kind. 

479. It is possible that the muscles and membranes of 
the jaw may be affected by the same causes which pro- 
duce the rheumatism in other parts; and it is also pos- 
sible, that a rheumatic diathesis at first produced by ir- 
ritation, may subsist in the muscles and membranes of 
the jaw, so that the inflammatory affection may be re- 
newed by certain causes without any new application of 
acrid matter. But I am persuaded that either of these 
occurrences are very rare, and I have never been able 
to ascertain any cases of toothach to be of these kinds. 
I consider it, therefore, as highly probable, that this 
rheumatic affection of the jaws which we name tooth- 
ach, is always dependent upon some immediate applica- 
tion of acrid matter to the nerves of the teeth. 

480. It is however to be observed, that this applica- 
tion of acrid matter does not always excite a pain in the 
tooth itself, or an inflammatory affection of the neigh- 
bouring parts; but that it very often operates by pro- 
ducing a diathesis only ; so that cold applied to the neigh- 
bouring parts does excite both a pain in the tooth, and 
an inflammatory affection of the neighbouring parts 
which did not appear before. 

There seems to be also certain states of the body, 
which operate upon the same diathesis so as to produce 
toothach. Such seems to be the case of pregnant 
women, who are more liable lo toothach than other 



PRACTICE OF PHYSIC. 315 

women. There are probably also some cases of in- 
creased irritability, which render persons more subject 
to toothach. Thus women are more liable to the dis- 
ease than men, and particularly women liable to hys- 
teric affections. 

481. The acrid matter producing this disease, seems 
to be generated first in the hard substances of the teeth: 
and as it often appears first upon the external surface of 
these, it might be suspected to arise from the applica- 
tion of external matters to the teeth. But as the pro- 
duction of this acrimony is often begun in the internal 
cavity of the teeth, where the operation of external mat- 
ters cannot be suspected, and as even when it begins 
upon the external parts of the teeth, the operation of 
the cause is at first in a small portion of the teeth only, 
that it is difficult to suppose that any matter externally 
applied could act in such a partial manner; so it is pre- 
sumed that the acrid matter occasioning the toothach, 
is produced by some vice originating in the substance of 
the tooth itself. When it begins upon the external sur- 
face, it is on the enamel ; but upon the internal surface, 
it must be in the bony part. From what cause it arises 
in either of these substances, I do not at all know; but 
I suspect that it often arises from some more general 
fault in the fluids of the body. The frequent use of 
mercury, especially when thrown much upon the mouth, 
and the state of the fluids in scurvy, seem both of them 
to give a disposition to a caries in the teeth; and it is 
possible that some other acrimonious states of the fluids 
may have the same effect. 

482. A caries in some part of the teeth, whether aris- 
ing upon their internal surface, or uponth ir external, 
proceeding so far as to reach the nerves in the cavity of 
the teeth, is pretty manifestly the cause of toothach, and 
of the first attacks of it; but when the cavity of the teeth 



316 PRACTICE OF PHYSIC. 

has been opened, so that the external air or other matters 
can reach that cavity, these are often the exciting causes 
of toothach, and serve to prove in general, that acrid 
matters applied to the nerves occasion the disease. 

483. What is the nature of the matter produced in 
the caries of the teeth, I do not understand, nor have I 
found any proper corrector of it ; but I presume it to be 
of the putrid kind, as it often taints the breath with a 
fetid odour. 

484. In the cure of this disease, a long experience has 
shown, that the extraction of the carious tooth proves 
the most effectual, and very often the only effectual, re- 
medy of the disease. But as in some cases this extrac- 
tion is not proper, and as in many cases it is obstinately 
avoided, other means of curing the disease, or at least 
of relieving the pain, have been sought for and much 
practised. 

485. Among these remedies, those are likely to be 
the most effectual which entirely destroy the affected 
nerve, or at least so much of it as is exposed to the 
action of the acrid matter in the tooth. When an open- 
ing is made into the cavity of the tooth, the nerve of it 
may be destroyed most certainly by the actual cautery; 
and it may also possibly be done by the application of 
potential caustics, either of the alkaline or acid kind. 

486. When these remedies cannot be rendered effec- 
tual, relief may often be obtained by diminishing the 
sensibility of the nerve affected, by the application of 
opium, or of the more acrid aromatic oils, and directly 
to the nerve in the tooth. It appears also, that the sensi- 
bility of the affected nerve may often be for some time 
diminished by the external application of opium to the 
extremities of those nerves in the skin, which are 



PRACTICE OF PHYSIC. 317 

branches of the same fifth pair of nerves with those of 
the teeth.* 

487. When the disease consists entirely in a pain of 
the nerve of the tooth, without any considerable affec- 
tion communicated to the neighbouring parts, the 
remedies already mentioned are those especially to be 
employed-, but when the disease consists very much in 
an inflammatory affection of the muscles and membranes 
of the jaw, and when at the same time there is little or 
no access for the above-mentioned remedies to the 
affected nerve, other measures are to be employed for 
relieving the disease. 

- 488. If the disease be attended with any general phlo- 
gistic diathesis of the system, or with any considerable 
degree of pyrexia, a general bleeding may be useful in 
relieving the disease: but these circumstances occur 
very rarely, and the disease is for the most part a purely 
topical affection; in which, as I observed before, a 
general bleeding is of very little service. As this dis- 
ease, however, is a topical inflammation, it might be 
supposed that topical bleedings would be very useful, 
and sometimes they are so; but it is seldom that their 
effects are either considerable or permanent. The 
reasons of this I take to be, that the disease does not 
consist in an affection of the blood-vessels alone, as in 
the ordinary cases of rheumatism; but in a peculiar 
affection of the fibres both ef the muscles and of the 
vessels of the part induced by irritation. The in- 
efficacy of topical bleedings is with me a proof of the 
disease being of the latter kind. 

* In a case of toothach, a small portion of the oleum origani, or of the 
essential oil of cloves, introduced into the cavity of the carious tooth, seldom 
fails to afford, at least, a temporary relief. So, if used in the same way, does 
opium, camphor, alkohol, and various other stimulating substances. But, 
by irritating and inflaming the gums, with which they cannot fail to come in 
contact, we apprehend that these articles, if long continued, increase, a f 
length, the malady they are intended to. relieve. 



318 PRACTICE OF PHYSIC. 

489. The remedies therefore necessary to give relief 
in this disease, are those which take off the spasm of the 
vessels, and especially of the muscles and membranes 
affected. Such are blistering, brought as near to the part 
affected as can be conveniently done; and such are also 
increased excretions excited in the neighbouring parts, 
as of the saliva and mucus of the mouth by the use of 
acrid masticatories. It is often sufficient to excite a strong 
sensation in the neighbouring parts ; as by eau de luce, 
Spirit of lavender, or Hungary water snuffed up the 
nostrils; or by the vitriolic aether properly applied to 
the cheek. It is upon the same footing that I suppose 
brandy or other ardent spirit held in the mouth is often 
of service.* 

490. There are cases of toothach in which it does not 
appear that the disease arises from an acrid matter im- 
mediately applied to the nerve of a tooth; but from the 
external application of cold, or some other causes im- 
mediately applied to the muscles and membranes of the 
jaw; and which therefore seem to require some remedies 
different from those above mentioned. But in all sucli 
cases, it is to be suspected, that the effects of cold, or 
of other such causes, are owing to a diathesis produced 
by an acrid matter applied to the nerve of a tooth, and 
continuing in some measure to act there ; and we have 
accordingly often found, that the action of those external 
causes were to be obviated only by the extraction of the 
tooth from which the diathesis had arisen. 

* Blisters, or sinapisms, applied to the cheek, or behind the ear, afford, 
frequently, great relief to an aching tooth. 

The chewing of such acrid, stimulating substances, as make a strong im- 
pression on the mouth and fauces, and provoke a copious secretion of saliva, 
produces, for the most part, a similar effect. So does the scarification of the 
gum around the tooth. 

These, however, are but palliative remedies. The only one from which 
a radical cure is to be expected, is, the extraction of the tooth. 






PRACTICE OF PHYSIC. 319 

CHAPTER XIV. 
OF THE GOUT.* 

491. THE Gout, not only as it occurs in different per- 
sons, but even as it occurs in the same person at differ- 
ent times, is a disease of such various appearance, that 
it is difficult to render the history of it complete and 
exact, or to give a character of it that will universally 
apply. However, I shall endeavour to describe the dis- 
ease as it most commonly appears, and to mark the 
varieties of it as well as I can. From such a history I 
expect that a general character may be given ; and such 
I think is the following, as given in the last edition of 
our Nosology: 

Gen. XXIII. Podagra. — Morbus hasreditarius, ori- 
ens sine causa externa evidente, sed prseeunte plerum- 
que ventriculi affectione insolita; pyrexia; dolor ad 
articulum et plerumque pedis pollici, certe pedum et 
manuum juncturis, potissimum infestus; per intervalla 
revertens, et saepe cum ventriculi, vel aliarum interna- 
rum partium affectionibus alternans. 

492. The Gout is generally a hereditary disease: but 

* Gout, more than almost any other disease, may be considered as growing 
literally out of the stomach. 

Whether it arise from a hereditary predisposition, from a long continued 
and laborious pursuit of letters, or from an inordinate devotion to the plea- 
sures of the table, or of love, the stomach is the organ that primarily suffers. 
It is there that the symptoms of an approaching paroxysm are first felt ; and 
to the same part alone, can remedies for it be directed, with any reasonable 
prospect of advantage. Applications to other parts afford relief; but if a 
cure by medicines ever be obtained, it must come from the stomach. 

We are apprehensive that women are as liable to this disease as men ; but 
they are attacked by it in a different shape ; which is not, therefore, gene- 
rally recognised as gout. What would be regular podagra in men, is colic, 
hysteria, sick headach, or some such anomalous complaint, in women. 



320 PRACTICE OF PHYSIC. 

some persons, without hereditary disposition, seem to 
acquire it; and, in some a hereditary disposition may be 
counteracted by various causes. These circumstances 
may seem to give exceptions to our general position; 
but the facts directly supporting it are very numerous. 

493. This disease attacks especially the male sex: but 
it sometimes, though more rarely, attacks also the fe- 
male. The females liable to it are those of the more ro- 
bust and full habits ; and it very often happens to such 
long before the menstrual evacuation has ceased. I have 
found it occurring in several females, whose menstrual 
evacuations were more abundant than usual. 

494. This disease seldom attacks eunuchs, and when 
it does, they seem to be those who happen to be of a 
robust habit, to lead an indolent life, and to live very 
full. 

495. The gout attacks especially men of robust and 
large bodies, men of large heads, of full and corpulent 
habits, and men whose skins are covered with a thicker 
rete mucosum, which gives a coarser surface. 

496. If with the ancients, we might ascertain, by cer- 
tain terms, the temperaments of men, I would say, that 
the gout attacks especially men of a cholerico-sanguine 
temperament, and that it very seldom attacks the purely 
sanguine or melancholic. It is, however, very difficult to 
treat this matter with due precision. 

497. The gout seldom attacks persons employed in 
constant bodily labour, or persons who live much upon 
vegetable aliment. It is also said to be less frequent 
among those people who make no use of wine or other 
fermented liquors. 

498. The gout does not commonly attack men, till 
after the age of five-and-thirty; and generally not till a 
still later period. There are indeed instances of the gout 
occurring more early; but these are few in comparison 



PRACTICE OF PHYSIC. 321 

of the numbers which agree with what we have given 
as the general rule. When the disease does appear 
early in life, it seems to be in those in whom the here- 
ditary disposition is very strong, and to whom the re- 
mote causes to be hereafter mentioned have been ap- 
plied in a considerable degree.* 

499. As the gout is a hereditary disease, and affects 
especially men of a particular habit, its remote causes 
may be considered as predisponent and occasional. 

500. The predisponent cause, so far as expressed by 
external appearances or by the general temperament, we 
have already marked; and physicians have been very 
confident in assigning the occasional causes: but, in a 
disease depending so much upon a predisposition, the 
assigning occasional causes must be uncertain; as in the 
predisposed, the occasional causes may not always ap-" 
pear, and in persons not predisposed, they may appear 
without effect. This uncertainty must particularly affect 
the case of the gout; but I shall offer what appears to 
me most probable on the subject. 

501. The occasional causes of the gout seem to be 
of two kinds. First, those which induce a plethoric 
state of the body. Secondly, those which, in plethoric 
habits, induce a state of debility. 

502. Of the first kind are a sedentary indolent man- 
ner of life, a full diet of animal food, and the large use 
of wine or of other fermented liquors. These circum- 
stances commonly precede the disease; and if there 
should be any doubt of their power of producing it, 
the fact, however, will be rendered sufficiently proba- 
ble by what has been observed in 497. 

503. Of the second kind of occasional causes which 

* We have known a boy of about six years old to sustain a regular parox- 
ysm of podagra. For several generations gout had been a disease ef his pa- 
"ernal ancestors. 

VOL. J-. S a 



322 PRACTICE OF PHYSIC, 

induce debility are, excess in venery; intemperance in 
the use of intoxicating liquors; indigestion, produced 
either by the quantity or quality of aliments; much ap- 
plication to study or business; night watching; exces- 
sive evacuations; the ceasing of usual labour; the sud- 
den change from a very full to a very spare diet; the 
large use of acids and acescents; and, lastly, cold ap- 
plied to the lower extremities.* 

504. The first (502.) seem to act by increasing the 
predisposition. The last (503.) are commonly the ex- 
citing causes, both of the first attacks, and of the re- 
petitions of the disease. 

505. It is an inflammatory affection of some of the 
joints, which especially constitutes what we call a pa- 
roxysm of the gout. This sometimes comes on sud- 
denly without any warning, but is generally preceded 
by several symptoms; such as the ceasing of a sweating 
which the feet had been commonly affected with be- 
fore; an unusual coldness of the feet and legs; a fre- 
quent numbness, alternating with a sense of prickling 
along the whole of the lower extremities; frequent 
cramps of the muscles of the legs; and an unusual tur- 
gescence of the veins. 

506. While these symptoms take place in the lower 
extremities, the whole body is affected with some de- 
gree of torpor and languor, and the functions of the sto- 
mach in particular are more or less disturbed. The 
appetite is diminished, and flatulency, or other symp- 
toms of indigestion, are felt. These symptoms, and 
those of 505. take place for several days, sometimes 
for a week or two, before a paroxysm comes on ; but 



* None of these causes ever produces gout, until it has first impaired the 
fone of the stomach. But when the sound state of that organ has given 
way, gout is likely very soon to follow. 



PRACTICE OF PHYSIC. 323 

commonly, upon the day immediately preceding it, the 
appetite becomes greater than usual. 

507. The circumstances of paroxysms are the fol- 
lowing. They come on most commonly in the spring, 
and sooner or later, according as the vernal heat suc- 
ceeds sooner or later to the winter's cold; and perhaps 
sooner or later also according as the body may happen 
to be more or less exposed to vicissitudes of heat and 
cold. 

508. The attacks are sometimes felt first in the even- 
ing, but more commonly about two or three o'clock oi 
the morning. The paroxysm begins with a pain affect- 
ing one foot, most commonly in the ball or first joint of 
the great toe, but sometimes in other parts of the foot. 
With the coming on of this pain, there is commonly 
more or less of a cold shivering, which, as the pain in- 
creases, gradually ceases, and is succeeded by a hot 
stage of pyrexia, which continues for the same time 
with the pain itself. From the first attack, the pain be- 
comes by degrees more violent, and continues in this 
state, with great restlessness of the whole body, till next 
midnight, after which it gradually remits; and, after it 
has continued for twenty-four hours from the com- 
mencement of the first attack, it commonly ceases very 
entirely, and, with the coming on of a gentle sweat, al- 
lows the patient to fall asleep. The patient, upon com- 
ing out of this sleep in the morning, finds the pained 
part affected with some redness and swelling, which, 
after having continued for some days, gradually abate. 

509. When a paroxysm has thus come on, although 
the violent pain after twenty-four hours be considerably 
abated, the patient is not entirely relieved from it. For 
some days he has every evening a return of more con- 
siderable pain and pyrexia, and which continue with 
more or less violence till morning. After continuing 



32 t PRACTICE OF PHYSIC. 

in this manner for several clays, the disease sometimes 
goes entirely off, not io return till after along interval. 

510. When the disease, after having thus remained 
for some time in a joint, ceases very entirely, it gene- 
rally leaves the person in very perfect health, enjoying 
greater ease and alacrity in the functions of both body 
and mind, than he had for a long time before expe- 
rienced* 

511. At the beginning of the disease, the returns of 
it are sometimes only once in three or four years: but, 
after some time, the intervals become shorter, and the 
attacks become annual; afterwards they come twice 
each year, and at length recur several times during the 
whole course of autumn, winter, and spring; and as it 
happens that, when the fits are frequent, the paroxysms 
become also longer, so, in the advanced state of the 
disease, the patient is hardly ever tolerably free from 
it, except perhaps for two or three months in summer. 

512. The progress of the disease is also marked by 
the parts which it affects. At first, it commonly affects 
one foot only; afterwards every paroxysm affects both 
feet, the one after the other; and as the disease conti- 
nues to recur, it not only affects both feet at once, but 
after having ceased in the foot which was secondly at- 
tacked, returns again into the foot first affected, and per- 
haps a second time also into the other. Its changes of 
place are not only from one foot to the other, but also 
from the feet into other joints, especially those of the 
upper and lower extremities; so that there is hardly a 
joint of the body that is not, on one occasion or other, 
affected. It sometimes affects two different joints at 
the same time; but more commonly it is severe in a sin- 
gle joint only, and passes successively from one joint to 

* The morbid irritation under which the stomach had laboured, is no:v 
-gone, and the system enjoys uninterrupted health. 



PRACTICE OF PHYSIC, 325 

another; so that the patient's affliction is often protracted 
for ;i long time. 

513. When the disease has often returned, and the 
paroxysms have become very frequent, the pains are 
commonly less violent than they were at first; but the 
patient is more affected with sickness, and the other 
symptoms of the atonic gout, which shall be hereafter 
mentioned.* 

514. After the first paroxysms of the disease, the 
joints which have been affected are entirely restored to 
their former suppleness and strength: but after the dis- 
ease has recurred very often, the joints affected do nei- 
ther so suddenly nor so entirely recover their former 
state, but continue weak and stiff; and these effects at 
length proceed to such a degree, that the joints lose 
their motion altogether. 

515. In many persons, but not in all, after the disease 
has frequently recurred, concretions of a chalky nature 
are formed upon the outside of the joints, and for the 
most part immediately under the skin. The matter 
seems to be deposited at first in a fluid form, but after- 
wards becomes dry and firm. In their dry state, these 
concretions are a friable earthy substance, very entirely 
soluble in acids. After they have been formed, they 
contribute, with other circumstances, to destroy the 
motion of the joint. 

516. In most persons who have laboured under the 
gout for many years, a nephritic affection comes on, and 
discovers itself by all the symptoms which usually at- 
tend calculous concretions in the kidneys, and which 
we shall have occasion to describe in another place. 
All that is necessary to be observed here is, that the 

* As the stomach becomes more and more weakened, it is less able to 
throw the disease completely on another part of the system. Hence it is 
obliged constantly to retain some portion of it itself. 



326 PRACTICE OF PHYSIC. 

nephritic affection alternates with paroxysms of the 
gout; and that the two affections, the nephritic and the 
gouty, are hardly ever present at the same time. This 
also may be observed, that children of gouty or nephri- 
tic parents commonly inherit one or other of these 
diseases; but which ever may have been the principal 
disease of the parent, some of the children have the 
one, and some the other. In some of them, the ne- 
phritic affection occurs alone, without any gout super- 
vening; and, this happens to be frequently the case of 
the female offspring of gouty parents. 

517. In the whole of the history already given, I have 
described the most common form of the disease; and 
which therefore, however diversified in the manner I 
have said, may be still called the regular state of the 
gout. Upon occasion, however, the disease assumes 
different appearances; but, as I suppose the disease to 
depend always upon a certain diathesis or disposition of 
the system; so every appearance which we can per- 
ceive to depend upon that same disposition, I shall con- 
sider as a symptom and case of the gout. The princi- 
pal circumstance in what we term the Regular Gout, 
is the inflammatory affection of the joints; and, what- 
ever symptoms we can perceive to be connected with, 
or to depend upon, the disposition which produces that 
inflammatory affection, but without its taking place, or 
being present at the same time, we name the Irregular 
Gout* 

518. Of such irregular gout there are three different 

* Young practitioners ought to be exceedingly attentive to the irregular 
forms, or appearances of gout, lest they should mistake them for some 
other disease. Such mistake might lead to a practice discreditable to them- 
selves, and injurious to their patients. The history of the sick, connected 
with that of their family and ancestors, will generally enable a physician of 
discernment to determine with correctness, whether their complaint be 
gout or not. To these circumstances let practitioners, particularly at the 
commencement of their professional course, pay the strictest attention. 



PRACTICE OF PHYSIC. 327 

states, which I name the atonic, the retrocedent, and the 
misplaced gout. 

519. The atonic state is when the gouty diathesis pre- 
vails in the system, but, from certain causes, does not 
produce the inflammatory affection of the joints. In 
this case, the morbid symptoms which appear are 
chiefly affections of the stomach; such as, loss of appe- 
tite, indigestion, and its various circumstances of sick- 
ness, nausea, vomiting, flatulency, acrid eructations, and 
pains in the region of the stomach. These symp- 
toms are frequently accompanied with pains and cramps 
in several parts of the trunk, and the upper extremities 
of the body, which are relieved by the discharge of wind 
from the stomach. Together with these affections of 
the stomach, there commonly occurs acostiveness; but 
sometimes a looseness with colic pains. These affec- 
tions of the alimentary canal are often attended with 
all the symptoms of hypochondriasis; as dejection of 
mind, a constant and anxious attention to the slightest 
feelings, an imaginary aggravation of these, and an ap- 
prehension of danger from them. 

In the same atonic gout, the viscera of the thorax 
also are sometimes affected, and palpitations, faintings, 
and asthma, occur. 

In the head also occur, headachs, giddiness, apoplec- 
tic and paralytic affections.* 

520. When the several symptoms now mentioned 
occur in habits having the marks of a gouty disposition, 
this maybe suspected to have laid the v foundation of 
them, and especially when either, in such habits, a 
manifest tendency to the inflammatory affection has 
formerly appeared; or when the symptoms mentioned 

* We believe that a great majority of apoplectic and paralytic cases are 
nothing else than irregular gout. They certainly have their seat in the sto- 
mach, and attack the brain through the medium of sympathy. Hence thr 
importance of plentiful purging in them 



328 PRACTICE OF PHYSIC. 

are intermixed with, and are relieved by, some degree 
of the inflammatory gout. In such cases there can be no 
doubt of considering the whole as a state of the gout. 

521. Another state of the disease I name the retro- 
cedent gout. This occurs when an inflammatory state 
of the joints has, in the usual manner, come on, but 
which, without arising to the ordinary degree of pain 
and inflammation, or, at least, without these continuing 
for the usual time, and receding gradually in the usual 
manner, they suddenly and entirely cease, while some 
internal part becomes affected. The internal part 
most commonly affected is the stomach, which is then 
affected with anxiety, sickness, vomiting, or violent 
pain; but sometimes the internal part is the heart, 
which gives occasion to a syncope; sometimes it is the 
lungs which are affected with asthma; and sometimes 
it is the head, giving occasion to apoplexy or palsy. In 
all these cases, tiiere can be no doubt of the symptoms 
being all a part of the same disease, however different 
the affection may seem to be in the parts which it at- 
tacks. 

522. The third state of irregular gout, which we 
name the misplaced, is when the gouty diathesis, in- 
stead of producing the inflammatory affection of the 
joints, produces an inflammatory affection of some in- 
ternal part, and which appears from the same symp- 
toms that attend the inflammation of those parts arising 
from other causes. 

Whether the gouty diathesis does ever produce such 
inflammation of the internal parts without having first 
produced it in the joints, or if the inflammation of the 
internal part be always a translation from the joints 
previously affected, I dare not determine; but, even 
supposing the latter to be always the case, I think the 
difference of the affection of the internal part must still 



PRACTICE OF PHYSIC. 329 

distinguish the misplaced from what I have named the 
retrocedent gout* 

523. What internal parts may be affected by the 
misplaced gout I cannot precisely say, because I have 
never met with any cases of the misplaced gout in my 
practice; and I find no cases of it distinctly marked by 
practical writers, except that of a pneumonic inflamma- 
tion. 

52 4 There are two cases of a translated gout; the 
one of which is an affection of the neck of the blad- 
der, producing pain, strangury, and a catarrhus vesicas: 
The other is an affection of the rectum, sometimes by 
pain alone in that part, and sometimes by hsemorrhoi- 
dal swelling there. In gouty persons, I have known 
such affections alternate with inflammatory affection of 
the joints: but whether to refer those affections to the 
retrocedent, or to the misplaced gout, I will not pre- 
sume to determine. 

525. From the history which I have now delivered 
of the gout, I think it may be discerned under all its 
various appearances. It is, however, commonly sup- 
posed, that there are cases in which it may be difficult 
to distinguish gout from rheumatism, and it is possible 
there may be such cases: but, for the most part, the 
two diseases may be distinguished with great certainty 
by observing the predisposition, the antecedents, the 
parts affected, the recurrences of the disease, and its 
connexion with the other parts of the system; which 
circumstances, for the most part, appear very differ- 
ently in the two diseases.f 

* Our author's remarks on the misplaced gout are vague and unsatisfac. 
tory— wholly insufficient to establish it as a stated form of the disease. For 
aught he has said on the subject, it might be rejected entirely from systems 
of nosology, and none but the atonic and retrocedent forms of irregular gout 
be retained. 

f We apprehend the most radical and essential difference between gout 
VOL. I. T t 



330 PRACTICE OF PHYSIC. 

526. With respect to the gout, our next business is 
to investigate its proximate cause; which must be a 
difficult task, and I attempt it with some diffidence. 

527. Upon this subject, the opinion which has ge- 
nerally prevailed is, that the gout depends upon a cer- 
tain morbific matter, always present in the body; and 
that this matter, by certain causes, thrown upon the 
joints or other parts, produces the several phenomena 
of the disease. 

528. This doctrine, however ancient and general, 
appears to me very doubtful; for, 

First, There is no direct evidence of any morbific 
matter being present in persons disposed to the gout. 
There are no experiments or observations which show 
that the blood, or other humours of gouty persons, are 
in any respect different from those of other persons, 
Previous to attacks of the gout, there appear no marks 
of any morbid state of the fluids; for the disease gene- 
rally attacks those persons who have enjoyed the most 
perfect health, and appear to be in that state when the 
disease comes on. At a certain period of the disease, 
a peculiar matter indeed appears in gouty persons: 

and rheumatism tobe, that the former always, and the latter never, originates 
in the stomach. In rheumatism the stomach is diseased; but its affection 
we believe to be, for the most part, secondary ,- whereas, in the gout, it is al- 
ways primary. 

Another well known difference is, that the gout usually attacks the smaller, 
and the rheumatism the larger joints of the body. To this rule, however, 
there exist exceptions; gout attacking, occasionally, almost every part of 
the system. 

The subjects of gout and rheumatism are, also, for the most part, differ- 
ent from each other, in their stations, habits, and modes of life. Gout at- 
tacks the wealthy and luxurious, who live at their ease; rheumatism those 
n humbler circumstances, who pursue a laborious mode of life Gout is a 
disease of more, rheumatism of less polished society. Hence the former is, 
in a great measure, confined to cities ; whereas the latter assails, indiffer- 
ently, the poor of cities, and the inhabitants of the country. 

Had we leisure to pursue the inquiry, we could make it appear, that th< 
inflammation of gout, like that of rheumatism, is of a specific character 



PRACTICE OF PHYSIC. 331 

515.) but this, which does not appear in every instance, 
and which appears only after the disease has subsisted 
for a long time, seems manifestly to be the effect, not 
the cause, of the disease. Further, though there be 
certain acrids, which, taken into the body, seem to ex- 
cite the gout, (503.) it is probable that these acrids ope- 
rate otherwise id exciting the disease, than by afford- 
ing the material cause of it. In general, therefore, 
there is no proof of any morbific matter being the cause 
of the gout. 

Secondly, The suppositions concerning the particu- 
lar nature of the matter producing the gout, have been 
so various and so contradictory to each other, as to al- 
low us to conclude, that there is truly no proof of the 
existence of any of them. With respect to many of 
these suppositions, they are so inconsistent with che- 
mical philosophy, and with the laws of the animal eco- 
nomy, that they must be entirely rejected. 

Thirdly, The supposition of a morbific matter being 
the cause of the gout, is not consistent with the pheno- 
mena of the disease, particularly with its frequent and 
sudden translations from one part to another. 

Fourthly, The supposition is further rendered impro- 
bable by this, that, if a morbific matter did exist, its 
operation should be similar in the several parts which it 
attacks; whereas it seems to be very different, being sti- 
mulant, and exciting inflammation in the joints, but se- 
dative and destroying the tone in the stomach: which, 
upon the supposition of particular matter acting in both 
cases, is not to be explained by any difference in the 
part affected. 

Fifthly, Some facts, alleged in proof of a morbific 
matter, are not sufficiently confirmed, such as those 
which would prove the disease to be contagious. There 
is, however, no proper evidence of this, the facts given 



332 PRACTICE OF PHYSIC 

being not only few, but exceptionable; and the negative 
observations are innumerable. 

Sixthly, Some arguments brought in favour of a 
morbific matter, are founded upon a mistaken explana- 
tion. The disease has been supposed to depend upon 
a morbific matter because it is hereditary: but. the in- 
ference is not just; for most hereditary diseases do not 
depend upon any morbific matter, but upon a particu- 
lar conformation of the structure of the body, transmit- 
ted from the parent to the offspring; and this last appears 
to be particularly the case in the gout. It may be also 
observed, that hereditary diseases, depending upon a 
morbific matter, always appear much earlier in life than 
the gout commonly does. 

Seventhly, The supposition of a morbific matter be- 
ing the cause of the gout, has been hitherto useless, as 
it has not suggested any successful method of cure. 
Particular suppositions have often corrupted the prac- 
tice, and have frequently led from those views which 
might be useful, and from that practice which experi- 
ence had approved. Further, though the supposition 
of a morbific matter has been generally received, it has 
been as generally neglected in practice. When the gout 
has affected the stomach, nobody thinks of correcting 
the matter supposed to be present there, but merely of 
restoring the tone of the moving fibres. 

Eighthly, The supposition of a morbific matter is 
quite superfluous; for it explains nothing, without sup- 
posing that matter to produce a change in the state of 
the moving powers, and a change in the state of the 
moving powers, produced by other causes, explains 
every circumstance, without the supposition of a mor- 
bific matter; and, to this purpose, it may be observed, 
that many of the causes (503.) exciting the gout, do not 
operate upon the state of the fluids, but directly and 
solely upon that of the moving powers. 



PRACTICE OF PHYSIC. 333 

Lastly, The supposition of a morbific matter is also 
superfluous; because, without any such supposition, I 
think the disease can be explained in a manner more 
consistent with its phenomena, with the laws of the ani- 
mal economy, and with the method of cure which ex- 
perience has approved. 

I now proceed to give this explanation; but, before 
entering upon it, I must premise some general observa- 
tions.* 

529. The first observation is, that the gout is a dis- 
ease of the whole system, or depends upon a certain ge- 
neral conformation and state of the body, which mani- 
festly appears from the facts mentioned from 493. to 
496. But the general state of the system depends 
chiefly upon the state of its primary moving powers; 
and therefore the gout may be supposed to be chiefly 
an affection of these.f 

530. My second observation is, that the gout is ma- 
nifestly an affection of the nervous system; in which 
the primary moving powers of the whole system are 
lodged. The occasional or exciting causes (503.) are 
almost all such as act directly upon the nerves and ner- 
vous system; and the greater part of the symptoms of 
the atonic or retrocedent gout are manifestly affections 
of the same system, (519. and 521.) This leads us to 



* The very name of Gout, being derived from the French word Goutc. 
a drop — that of rheumatism, from the Greek word *psa>, to flow, convinces us 
that, originally, both diseases were supposed to arise from a vitiation of the 
fluids. But, for the reasons assigned by Dr. Cullen, in addition to what wc 
have ourselves said, on several occasions, in opposition to the humoral pa- 
thology in every shape, the hypothesis must be ultimately and for ever aban- 
doned. Rheumatism, gout, and all other complaints, originate in the solids ; 
the disease arising from the exclusion of respirable air from the lungs ex- 
cepted. 

f Gout is a disease of the whole system, -when it has become so by sympathy. 
But ; like every other complaint, it is at first local. It commences in the sto- 
mach, and spreads by degrees to the other parts of the body. 



334 PRACTICE OF PHYSIC 

seek for an explanation of the whole of the disease in 
the laws of the nervous system, and particularly the 
changes which may happen in the balance of its seve- 
ral parts * 

531. My third observation is, that the stomach, which 
has so universal a consent with the rest of the system, 
is the internal part that is the most frequently, and often 
very considerably affected by the gout. The paroxysms 
of the disease are commonly preceded by an affection 
of the stomach; (506.) many of the exciting causes 
(503.) act first upon the stomach; and the symptoms of 
the atonic and retrocedent gout (519. 521.) are most 
commonly and chiefly affections of the same organ. 
This observation leads us to remark, that there is a ba- 
lance subsisting between the state of the internal and 
that of the external parts; and, in particular, that the 
state of the stomach is connected with that of the ex- 
ternal parts; (44.) so that the state of tone in the one 
may be communicated to the other. 

532. These observations being premised, I shall now 
offer the following pathology of the gout. 

In some persons there is a certain vigorous and ple- 
thoric state of the system (495.) which, at a certain pe- 
riod of life, is liable to a loss of tone in the extremities, 
(498. 505.) This is in some measure communicated to 
the whole system, but appears more especially in the 
functions of the stomach, (506.) When this loss of tone 
occurs while the energy of the brain still retains its vi- 
gour, the vis medicatrix naturae is excited to restore the 
tone of the parts; and accomplishes it by exciting an 
inflammatory affection in some part of the extremities. 
When this has subsisted for some days, the tone of the 

* We have already observed, and here repeat, that the prima: viae, more 
particularly the stomach, constitute the seat of that family of diseases that 
are now called nervous. 



PRACTICE OF PHYSIC. 335 

extremities, and of the whole system are restored, and 
the patient returns to his ordinary state of health, (510.)* 

533. This is the course of things, in the ordinary 
form of the disease, which we name the regular gout; 
but there are circumstances of the body, in which this 
course is interrupted or varied. Thus when the atony 
(505. 506.) has taken place, if the reaction (508.) do not 
succeed, the atony continues in the stomach, or perhaps 
in other internal parts, and produces that state which 
we have, for reasons now obvious, named the atonic gout. 

534. A second case of variation in the course of the 
gout is, when, to the atony, the reaction and inflamma- 
tion have to a certain degree succeeded; but, from causes 
either internal or external, the tone of the extremities, 
and perhaps of the whole system, is weakened ; so that 
the inflammatory state, before it had either proceeded to 
the degree, or continued for the time, requisite for re- 
storing the tone of the system, suddenly and entirely 
ceases. Hence the stomach, and other internal parts, 
relapse into the state of atony: and perhaps have this 
increased by the atony communicated from the extre- 

* This is just as correct and intelligible as most of our author's specula- 
tions touching tiie proximate causes of disease. In other words, it is " voces 
iiianx etpraterea niltil." 

All we shall venture to say, at present, respecting the philosophy of gout, 
is, that the disease begins at a point in the stomach, and extends by sympa- 
thy to the rest of the system. But we do not pretend to understand either 
the principles of this sympathetic extension, or the peculiar kind of morbid 
action in which gout consists. A knowledge of these points is reserved for 
a period of greater advancement in pathological science. 

If gout be, as we believe and have pronounced it, a disease of a specific 
character, it is then on a level with all other complaints of the same descrip- 
tion — not -understood: for, by specific action, whether in physiology, pathology, 
or therapeutics, we mean an ultimate fact — something that we do not com- 
prehend, and cannot explain, in as much as we have no standard of compari- 
son by which we can throw light on it, either to ourselves or others. 

Irregular gout occurs, when, by debility, exhaustion, or other causes, the 
chain of sympathy, if we may so express ourselves, between the stomach 
and the lower extremities, :s interrupted or broken. 



836 PRACTICE OF PHYSIC. 

mities: All which appears in what we have termed the 
retrocrdent gout. 

535. A third case of variation from the ordinary 
course of the gout, is, when, to the atony usually pre- 
ceding, an inflammatory reaction fully succeeds, but 
has its usual determination to the joints by some cir- 
cumstances prevented; and is therefore directed to an 
internal part, where it produces an inflammatory affec- 
tion, and that state of things which we have named the 
misplaced gout. 

536. We have thus offered an explanation of the cir- 
cumstances of the system in the several states of the 
gout; and this explanation we suppose to be consistent 
with the phenomena of the disease, and with the laws of 
the animal economy. There are indeed, with respect to 
the theory of the disease, several questions which might 
be put, to which we have not given any answer. But, 
though perhaps we could give an answer to many of 
these questions, it does not here appear necessary; as at 
present we intend only to establish such general facts, 
with regard to this disease, as may lay a foundation for 
the cure of it, so far as experience has enabled us to 
prosecute it. Proceeding, therefore, upon the several 
parts of the pathology given, as so many matters of fact, 
I shall now consider what may be attempted towards the 
cure of the disease. 

537. In entering upon this, I must observe, in the 
first place, that a cure has been commonly thought im- 
possible; and we acknowledge it to be very probable, 
that the gout, as a disease of the whole habit, and very 
often depending upon original conformation, cannot be 
cured by medicines, the effects of which are always very 
transitory, and seldom extend to the producing any 
considerable change of the whole habit.* 

* Completely to eradicate a strong hereditary predisposition to gout, we 



PRACTICE OF PHYSIC. 337 

o38. It would perhaps have been happy for gouty 
persons, if this opinion had been implicitly received by 
them; as it would have prevented their having been so 
often the dupes of self-interested pretenders, who have 
either amused them with inert medicines, or have rashly 
employed those of the most pernicious tendency. I am 
much disposed to believe the impossibility of a cure of 
the gout by medicines; and more certainly still incline 
to think, that whatever may be the possible power of 
medicines, yet no medicine for curing the gout has 
hitherto been found. Although almost every age has 
presented a new remedy, yet all hitherto offered have 

believe to be as impracticable, as it would be to remove a hereditary like- 
ness in feature or figure, complexion or size. It is so inextricably inter- 
woven with the texture of certain organs, as to constitute, perhaps, essen- 
tially, a part of the system. But, by steadily persevering in a suitable regi- 
men, it may be, if not actually weakened, at least prevented from acquiring 
any additional strength : while a cautious avoidance of exciting causes, will, 
if not always, at least in most instances, effectually stay its progress towards 
disease. 

Our author's observations, on the regimen proper for persons predisposed 
to gout ; are so sensible and pertinent, ample and clearly expressed, that any 
addition to them might be deemed superfluous. They constitute as able a 
manifestation of practical wisdom and professional skill, as is any where to 
be found in the records of medicine. 

We shall only further observe, that, whatever co-operates with temper- 
ance in strengthening the system, particularly the stomach, and diminish- 
ing susceptibility, may be usefully employed as a preventive of gout. Of 
this description is travelling, and all manly and athletic exercises in the open 
air : these, however, should never be carried to the point of fatigue. Mode- 
ration in all things constitutes the true spirit of the regmen most suitable to 
those who are subject to gout. 

In persons whose predisposition to gout, instead of being hereditary, has 
been created by their own voluptuous practices and luxurious living, a 
change of life has effectually removed it. 

It must be acknowledged, however, that such instances are not very com- 
mon, and that success is always doubtful, where the meridian of life is al- 
ready past, and there has been a long and zealous devotion to convivial 
pleasures, to immoderate drinking, or to an excessive and illegitimate in- 
dulgence in love. Under circumstances like these, .t is perfectly true, as 
our author has stated, that a sudden change of life is neither a remedy uni- 
formly effectual, in the cure of gout, nor altogether unaccompanied with 
danger. 

VOL. I. TT „ 



338 PRACTICE OF PHYSU 

very soon been either neglected as useless, or con- 
demned as pernicious. 

539. Though unwilling to admit the power of medi- 
cines, yet I contend that a great deal can be done to- 
wards the cure of the gout bv a regimen: And from 
what has been observed (497.) I am firmly persuaded, 
that any man who, early in life, will enter upon the con- 
stant practice of bodily labour, and of abstinence from 
animal food, will be preserved entirely from the disease. 

Whether there be any other means of radically curing 
the gout I am not ready to determine. There are histo- 
ries of cases of the gout, in which it is said, that by 
great emotions of mind, by wounds, and by other accr- 
dents, the symptoms have been suddenly relieved, and 
never again returned; but how far these accidental cures 
might be imitated by art, or would succeed in other 
cases, is at least extremely uncertain. 

540. The practices proper and necessary in the treat- 
ment of the gout, are to be considered under two heads; 
first, As they are to be employed in the intervals of 
paroxysms; or, secondly, As during the time of these. 

541. In the intervals of paroxysms, the indications 
are, to prevent the return of paroxysms, or at least to 
render them less frequent, and more moderate. During 
the time of paroxysms, the indications are, to moderate 
the violence, and shorten the duration of them as much 
as can be done with safety. 

542. It has been already observed, that the gout may 
be entirely prevented by constant bodily exercise, and 
by a low diet: and I am of opinion, that this prevention 
may take place even in persons who have a hereditary 
disposition to the disease. I must add here, that even 
when the disposition has discovered itself by several 
paroxysms of inflammatory gout, I am persuaded that 
labour andabstinence will absolutely prevent any returns 



PRACTICE OF PHYSIC. 339 

it for the rest of life. These, therefore, are the means 
of answering the first indication to be pursued in the in- 
tervals of paroxysms; and I must here offer some re- 
marks upon the proper use of these remedies.* 

543. Exercise in persons disposed to the gout, is di- 
rected to two purposes: One of these is the strength- 
ening of the tone of the extreme vessels; ard the other 
the guarding against a plethoric stat<\ For the former, 
if exercise be employed early in life, and before intem- 
perance has weakened the body, a very moderate de- 
gree of it will answer the purpose; and for the latter, if 
abstinence be at the same time observed", little exercise 
will be necessary. 

544. With respect to exercise, this in general is to be 
observed, that it should never be violent; for if violent, 
it cannot be long continued, and must always endanger 
the bringing on an atony in proportion to the violence 
of the preceding exercise. 

545. It is also to be observed, that the exercise of 
gestation, though considerable and constant, if it be 
entirely without bodily exercise, will not answer the pur- 
pose in preventing the gout. For this end, therefore, 
the exercise must be, in some measure, that of the body, 
and must be moderate, but at the same time constant 
and continued through life. 

546. In every case and circumstance of the gout, in 
which the patient retains the use of his limbs, bodily 
exercise, in the intervals of paroxysms, will always be 
useful; and, in the beginning of the disease, when the 

* The Baron Van Swieten mentions the case of a priest, who, enjoying a 
rich living, had been an old and constant sufferer from the gout. But, being 
made a captive by the pirates of Barbary, he was detained in slavery for two 
years, and compelled to work in the galleys, supported only by a mesgre 
diet. He was at length ransomed, and the result was, that having lost his 
troublesome and cumbrous obesity, he had never afterwards a fit of the gout, 
but lived many years in the enjoyment of uninterrupted health. 



340 PRACTICE OF PHYSIC. 

disposition to it is not yet strong, exercise may prevent 
a paroxysm which otherwise might have come on. In 
more advanced states of the disease, however, when 
there is some disposition to a paroxysm, much walking 
will bring it on ; either as it weakens the tone of the 
lower extremities, or as it excites an inflammatory dis- 
position in them; and it is probable, that in the same 
manner strains or contusions often bring on a paroxysm 
or the gout* 

547. Abstinence, the other part of our regimen (539.) 
for preventing the gout, is of more difficult application. 
If an abstinence from animal food be entered upon early 
in life, while the vigour of the system is yet entire, we 
have no doubt of its being both safe and effectual; but if 
the motive for this diet shall not have occurred till the 
constitution shall have been broken by intemperance, 
or by the decline of life, a low diet may then endanger 
the bringing on an atonic state. 

548. Further, if a low diet be entered upon only in 
the decline of life, and be at the same time a very great 
change in the former manner of living, the withdraw- 
ing of an accustomed stimulus of the system may readily 
throw this into an atonic state.f 

549. The safety of an abstemious course may be 
greater or less according to the management of it. It 
is animal food which especially disposes to the plethoric 
and inflammatory state, and that food is to be therefore 
especially avoided ; but, on the other hand, it is vegetable 
aliment of the lowest quality that is in danger of weak- 
ening the system too much, by not affording sufficient 

* We have seen several instances, in which, in those predisposed to the 
disease, a strain or contusion of the foot has produced a regular paroxysm 
of podagra. The injury in such cases acts only as the exciting cause. 

f A sudden change from a full to a spare diet is mentioned, in article 503, 
as one of the occasional causes of gout. 



PRACTICE OF PHYSIC. 34 J 

nourishment; and more particularly of weakening the 
tone of the stomach by its acescency. It is therefore 
a diet of a middle nature that is to be chosen ; and milk 
is precisely of this kind, as containing both animal and 
vegetable matter. 

As approaching to the nature of milk, and as being a 
vegetable matter containing the greatest portion of nou- 
rishment, the farinaceous seeds are next to be chosen, 
and are the food most proper to be joined with milk. 

550. With respect to drink, fermented liquors are 
useful only when they are joined with animal food, and 
that by their acescency; and their stimulus is only ne- 
cessary from custom. When, therefore, animal food is 
to be avoided, fermented liquors are unnecessary; and, 
by increasing the acescency of vegetables, these liquors 
may be hurtful. The stimulus of fermented or spiritu- 
ous liquors, is not necessary to the young and vigorous; 
and, when much employed, impairs the tone of the sys- 
tem. These liquors, therefore, are to be avoided, ex- 
cept so far as custom and the declining state of the sys- 
tem may have rendered them necessary. For prevent- 
ing or moderating the regular gout, water is the only 
proper drink. 

551. With respect to an abstemious course, it has 
been supposed that an abstinence from animal food and 
fermented liquors, or the living upon milk and farinacea 
alone for the space of one year, might be sufficient for a 
radical cure of the gout; and it is possible that, at a 
certain period of life, in certain circumstances of the 
constitution, such a measure might answer the purpose. 
But this is very doubtful; and it is more probable that 
the abstinence must, in a great measure, be continued, 
and the milk diet be persisted in, for the rest of life' 
It is well known, that several persons who had entered 
on an abstemious course, and had been thereby deli- 



342 PRACTICE OF PHYSIC. 

vered from the gout, have, however, upon returning to 
their former manner of full living, had the disease re- 
turn upon them, with as much violence as before, or in 
a more irregular and more dangerous form.* 

552. It has been alleged, that, for preventing the 
return of the gout, blood-letting, or scarifications of 
the feet frequently repeated, and at stated times, may 
be practised with advantage; but of this I have had no 
experience. 

553. Exercise and abstinence are the means of avoid- 
ing the plethoric state which gives the disposition to the 
gout; and are therefore the means proposed for prevent- 
ing paroxysms, or at least for rendering them less fre- 
quent, and more moderate. But many circumstances 
prevent the steadiness necessary in pursuing these mea- 
sures; and therefore, in such cases, unless great care be 
taken to avoid the exciting causes, the disease may fre- 
quently return; and in many cases, the preventing of 
paroxysms is chiefly to be obtained by avoiding those 
exciting causes enumerated in 503. The conduct ne- 
cessary for avoiding them, will be sufficiently obvious to 
persons acquainted with the doctrines of the Hygieine, 
which I suppose to have been delivered in another place. 

55i. A due attention in avoiding those several causes, 
(502. 503.) will certainly prevent fits of the gout; and 
the taking care that the exciting causes be never applied 
in a great degree, will certainly render fits more mode- 
rate when they do come on. But, upon the whole, it 
will appear, that a strict attention to the whole conduct 
of life, is in this matter necessary; and therefore, when 
the predisposition has taken place, it will be extremely 
difficult to avoid the disease. 

* It is exceedingly improbable that any regimen or mode of life persisted 
in for only a year, and then abandoned, has ever effeeted, or ever will effect, 
a radical cure of gout. 



PRACTICE OF PHYSIC. 343 

555. I am indeed firmly persuaded, that, by obviating 
the predisposition, and by avoiding the exciting causes, 
the gout may be entirely prevented: but as the measures 
necessary for this purpose will, in most cases, be pur- 
sued with difficulty, and even with reluctance, men have 
been very desirous to find a medicine which might an- 
swer the purpose without any restraint on their manner 
of living. To gratify this desire, physicians have pro- 
posed, and, to take advantage of it, empirics have feign- 
ed, many remedies, as we have already observed. Of 
what nature several of these remedies have been, I can- 
not certainly say; but, of those which are unknown, we 
conclude, from their having been only of temporary fame, 
and from their having soon fallen into neglect, that they 
have been either inert or pernicious, and therefore I 
make no inquiry after them; and shall now remark only 
upon one or two known remedies for the gout, which 
have been lately in vogue. 

556. One of these is what has been named in Eng- 
land^ the Portland Powder. This is not a new medi- 
cimvbut is mentioned by Galen, and, with, some little 
variation in its composition, has been mentioned by the 
writers of almost every age since that time. It appears 
to have been at times in fashion, and to have again fallen 
into neglect; and I think that this last has been owing 
to its having been found to be, in many instances, per- 
nicious. In every instance which I have known of its 
exhibition for the length of time prescribed, the persons 
who had taken it were indeed afterwards free from any 
inflammatory affection of the joints; but they were af- 
fected with many symptoms of the atonic gout; and all, 
soon after finishing their course of the medicine, have 
been attacked with apoplexy, asthma, or dropsy, which 
proved fatal.* 

* The Portland Powder being rejected from practice, both in Eurorr. 



344 PRACTICE OF PHYSIC. 

557. Another remedy which has had the appearance 
of preventing the gout, is an alkali in various forms, 
such as the fixed alkali both mild and caustic, lime wa- 
ter, soap, and absorbent earths. Since it became com- 
mon to exhibit these medicines in nephritic and calcu- 
lous cases, it has often happened that they were given 
to those who were at the same time subject to the gout; 
and it has been observed, that under the use of these 
medicines, gouty persons have been longer free from the 
fits of their disease. That, however, the use of these 
medicines has entirely prevented the returns of gout, I 
do not know; because I never pushed the use of those 
medicines for a long time, being apprehensive that the 
long continued use of them might produce a hurtful 
change in the state of the fluids.* 



and America, an account of its composition would be altogether useless. It 
consisted of several vegetable articles, all of them bitter, aromatic, or other- 
wise stimulating, calculated, perhaps, to gn e, for a time, a factitious tone to 
the stomach, but not to augment its natural powers. On the other hand, it 
could no more fail to impair these powers, than the long continued and ex- 
cessive use of ardent spirits, Cayenne pepper, or any other powerfully sti- 
mulating condiment or drink. To say the least, it prevented one disease 
of the stomach only by producing another. 

* Several persons with whom we have conversed, fancy that their arthri- 
tic complaints have been much relieved, by the daily and long continued 
use of the hypercarbonated soda water. 

That some of the troublesome symptoms of gout have been thus miti- 
gated is probably true : but that the predisposition to the disease has ever 
been materially weakened by this remedy, is a position, which, as far as we 
are informed, there exists no satisfactory reason to believe. From the usual 
operation of soda and other absorbents on the system, we would not be led 
to consider them as efficacious remedies in the treatment of gout. We be- 
lieve their introduction and employment to have arisen from a false theory 
of the disease ; and that they have never yet received the sanction of expe- 
rience. When gout was supposed to originate from the presence of a su- 
perabundant acid in the system, alkalies and absorbents were resorted to 
as its most promising and natural remedies. But it being now acknowledged 
to be a disease of the solids, these remedies are no longer in such esteem. 

" The Eau Medicinale d'Husson, (says a British practical writer of consi- 
derable reputation,) is a remedy much in vogue, at present, in gouty at- 
tacks, and in some cases it appears to have considerably alleviated the pa- 



PRACTICE OF PHYSIC. 345 

o58 With respect to preventing the gout I have only 
One other remark to offer, As the preventing the gout 
depends very much on supporting the tone of the sto- 
mach, and avoiding indigestion; so costiveness, by occa- 
sioning this, is very hurtful to gouty persons. It is there- 
fore necessary for such persons to prevent or remove 
costiveness, and by a laxative medicine, when needful; 
but it is at the same time proper, that the medicine em- 
ployed should be such as may keep the belly regular, 
without much purging. Atactics, rhubarb, magnesia 



roxysm, but in a few others it lias produced alarming effects, such as syn- 
cope, cold sweats, extreme prostration of strength, excessive evacuations 
from the stomach and bowels, accompanied by a pulse scarcely perceptible, 
and a degree of insensibility that indicated approaching dissolution. Such 
consequences, however, have only ensued when an improper dose of the 
nostrum has been taken. Besides possessing the properties of an emetic 
and a cathartic, it appears also to be endowed with the properties of a nar- 
cotic, as in some instances it seems to act as an anodyne, previous to any 
sensible evacuation taking place." 

The Eau Medicinale is a vegetable preparation, of a bitter and nauseous 
taste, the composition of which remains a secret. Some suppose it to con- 
sist of white hellebore, others of gratiola or hedge-hyssop, a third class of 
the colchicum autumnale, or meadow saffron, and a fourth of the roots of* 
betony, infused in Spanish white wine, with the addition of tincture of 
opium. 

The experience of American physicians in the use of this nostrum is not 
very ample. As far, however, as it has extended, it has, we believe, tended 
somewhat to confirm the favourable opinion originally entertained of its anti- 
arthritic qualities. 

In the dose of from half a drachm to two drachms, taken in any conve- 
nient vehicle, it greatly mitigates the pain, and shortens the duration of the 
paroxysm, after it has occurred ; while, in doses of from ten drops to a scru- 
ple or half a drachm, it is found to prevent it, after the premonitions of its 
approach have been felt. 

We have no evidence of its being calculated to remove entirely the pre- 
disposition to gout; nor any of its tendency to produce on the stomach 
those deleterious effects which follow the use of Portland Powder. 

But, if it continue uniformly to relieve the pain and to protract the inter- 
vals of the paroxysms of gout, it cannot be otherwise regarded than as an 
important remedy. 

We regret to find that, in Great Britain, it does not altogether maintain 
its original character. 

In atonic gout, the pulvis sabins, in moderate doses, is a ttsefhl remedy. 
VOL. t. X X 



J46 PRACTICE OF PHYSIC. 

alba, or flowers of sulphur, may be employed, as the one 
or the other may happen to be best suited to particular 
persons. 

559. These are the several measures (from 541. to 
558.) to be pursued in the intervals of the paroxysms; 
and we are next to mention the measures proper during 
the time of them. 

560. As during the times of paroxysms the body is 
in a feverish state, no irritation should then be added 
to it; and every part, therefore, of the antiphlogistic re- 
gimen, (130. to 133.) except the application of cold, 
ought to be strictly observed. 

Another exception to the general rule may occur 
when the tone of the stomach is weak, and when the 
patient has been before much accustomed to the use of 
strong drink; for it then may be allowable, and even ne- 
cessary, to give some animal food, and a little wine* 

* We have never seen a case of regular gout accompanied with fever, 
in which the exhibition of either wine or animal food was admissible. Al- 
though we do not believe in the unity of disease, yet, practically speaking, 
inflammatory fever, whatever may be its name, is so far an unit, as to be 
always increased by the operation of stimulants. But the fever of real po- 
dagra is known to be inflammatory: it does not, therefore, admit of the ex- 
hibition of wine or animal food. 

If the form of gout be atonic; or the topical affection threaten to recede 
from the foot, and attack the stomach ; in either case, wine and other stimu- 
lants become essential. But in true podagra, when the pain is severe and 
the fever considerable, the action of the system should be diminished, not 
increased. We are convinced that the amount of suffering in regular gout 
is greatly augmented by the injudicious manner in which that complaint is 
generally treated — we ought rather to say, the actual neglect with which it is 
treated. 

On this subject, we can do nothing else so well calculated to instruct our 
readers, as to quote, from his manuscript lectures, the sentiments of our 
very able and distinguished friend, the present Professor of the Theory and 
Practice of Physic, in the University of Pennsylvania. 

" It may be proper for me in this place, (says the Professor,) to state, that 
the treatment of podagra or regular gout, by active purging, is a very ancient 
practice. It indeed prevailed, with no interruption, from the earliest times, 
until it was prohibited by Sydenham, on purely theoretical views: it being, 
he observes, ' an inviolable law of nature, that the matter of the disease 



PRACTICE OF PHYSIC. 347 

^61. That no irritation is to be added to the system 
during the paroxysms of gout, except in the cases men- 
tioned, is entirely agreed upon among physicians: But 

should be thrown out by the extremities, emetics and cathartics will have 
no other effect, than that of bringing back the offending matter to the 
bowels.' 

" Enslaved by the authority of Sydenham, we have ever since, with some- 
very limited exceptions, wholly abandoned the use of purgatives, and have 
been most commonly content to let the attack spontaneously exhaust itself. 
To envelope the limb with flannel, and to urge a patient endurance of the 
pain, constitute, indeed, proverbially, the amount of what is at present done 
in a regular paroxysm of gout. 

" It appears to me, that the example of Sydenham has been, in this case, 
exceedingly mischievous ; having led, in my opinion, to the desertion of a 
practice, which, if judiciously applied, is not only safe, but peculiarly calcu- 
lated to overcome this most distressing disease. 

" It would ill comport with my duties, were I to indulge in any minute, or 
lengthened disquisition respecting the nature and causes of gout. My im- 
pression, very concisely stated, is, that this disease, if not originating in, has 
a most intimate connection with, certain states of the alimentary canal. I am 
inclined to this view of the subject, from having so frequently observed gout 
to commence with the symptoms which denote a disordered condition of 
the stomach and bowels. The precursory indications of an approaching at- 
tack of this disease are, almost invariably, flatulence, sour eructations, indi- 
gestion, depraved appetite, nausea, strong sensations of internal heat, and 
obstinate constipation, or a lax and disordered state of the bowels. — 

— "But whether the opinion I have ventured to advance on this subject 
be right or wrong, (continues the Professor,) it may be confidently stated, 
that the practice it dictates is perfectly sound, and fully warranted by long 
and diversified experience. 

" I have now, for several years, habitually employed purgatives in the 
paroxysms of gout, and with unequivocal advantage. Wot content with 
simply opening' the bowels, I completely evacuate, by active purging, the 
entire alimentary canal. This being accomplished, all the distressing sen- 
sations of the stomach which I have mentioned are removed, the pain and 
inflammation of the limb gradually subside, and the paroxysm, thus broken, 
speedily passes away. To effect these purposes, however, it is often neces- 
sary to recur to the remedy repeatedly. 

" Though, in some instances, the operation of a single cathartic will be 
productive of considerable relief, it more generally requires successive purg- 
ing for several days to do it. 

" My practice has been, to administer every day, or every other day, a 
very large dose of rhubarb and magnesia, to produce a greater or lesser 
number of openings, according to the strength of the patient, and the vio- 
lence of the case." 

This statement of his own practice in regular gout, the Professor proceeds 
to corroborate by an account of that of other distinguished physicians cf 



348 PRACTICE OF PHYSIC 

it is a more difficult matter to determine whether, during 
the time of paroxysms, any measure may be pursued 
to moderate the violence of reaction and of inflamma- 
tion. Dr. Sydenham has given it as his opinion, that the 
more violent the inflammation and pain, the paroxysms 
will be the shorter, as well as the interval between 
the present and next paroxysm longer; and, if this 
opinion be admitted as just, it will forbid the use of any 
remedies which migiit moderate the inflammation ; which 
is, to a certain degree, undoubtedly necessary for the 
health of the body. On the other hand, acute pain 
presses for relief; and, although a certain degree of in- 
flammation may seem absolutely necessary, it is not cer- 
tain but that a moderate degree of it may answer the 
purpose: And it is even probable that, in many cases, 
the violence of inflammation may weaken the tone of 
the parts, and thereby invite a return of paroxysms. It 
seems to me to be in this way, that, as the disease ad- 
vances, the paroxysms become more frequent. 

562. From these last considerations, it seems pro- 
bable, that, during the time of paroxysms, some mea- 
sures may be taken to moderate the violence of the in- 
flammation and pain; and particularly, that in first pa- 
roxysms, and in the young and vigorous, blood-letting 
at the arm may be practised with advantage. But I am 
persuaded that this practice cannot be repeated often 
with safety; because blood-letting not only weakens the 

former times and distant countries. Indulging himself, here, in a rapid 
gLnce over the annals of medicine, he clearly shows, that from the time of 
Hippocrates to that of Sydenham, podagra was uniformly treated hy active 
purging : and further, that although the latter character, from the peculiarity 
of his views, and by the weight of his authority, rendered this mode of prac- 
tice somewhat unpopular it was, notwithstanding, pursued, until a much 
later period, hy some of the most eminent physicians of Europe. 

We regret exceedingly that our limits do not permit us to quote the whole 
of the Professor'* remarks and illustration's touching this subject, as they 
could not fail to prove highly interesting and instructive to our readers 



PRACTICE OF PHYSIC. 349 

tone of the system, but may also contribute to produce 
plethora. I believe, however, that bleeding by leeches on 
the foot, and upon the inflamed part, may be practised, 
and repeated with greater safety ; and I have known in- 
stances of its having been practised with safety, to mo- 
derate and shorten paroxysms; but how far it may be 
carried, we have not had experience enough to deter- 
mine. 

563. Besides blood-letting, and the antiphlogistic re- 
gimen, it has been proposed to employ remedies for 
moderating the inflammatory spasm of the part affected, 
such as warm bathing and emollient poultices. These 
have sometimes been employed with advantage and 
safety; but, at other times, have been found to give oc- 
casion to a retrocession of the gout. 

564. Blistering is a very effectual means of relieving 
and discussing a paroxysm of the gout ; but has also 
frequently had the effect of rendering it retrocedent* 

565. The stinging with nettles 1 consider as analogous 
to blistering; and I think it probable that it would be 
attended with the same danger. 

566. The burning with moxa, or other substances, I 
consider as a remedy of the same kind. I have had indeed 
no evidence of this proving hurtful; but neither have I 
had any proper evidence of its having proved a radical 
cure. 

567. Camphire, and some aromatic oils, have the 
power of allaying the pain, and of removing the inflam- 
mation from the part affected; but these remedies com- 
monly make the inflammation only shift from one part 

* In case of the retrocession of gout, blisters and sinapisms are useful 
remedies in recalling tlie topical affection to the extremities. But blister- 
ing the pari where the affection is already situated, with a view to its dis- 
cussion, is a practice, which, we believe, is very rarely pursued. We have 
never seen an instance of it, nor can we discover any correctness of principle 
on which it is founded. 



350 PRACTICE OF PHYSIC. 

to another, and therefore with the hazard of its falling 
upon a part where it may be more dangerous: and they 
have sometimes rendered the gout retrocedent. 

568. From these reflections (563. et seq.) it will ap- 
pear that some danger must attend every external ap- 
plication to the parts affected during a paroxysm; and 
that therefore the common practice of committing the 
person to patience and flannel alone, is established upon 
the best foundation.* 

569. Opiates give the most certain relief from pain; 
but, when given in the beginning of gouty paroxysms, 
occasion these to return with greater violence. When, 
however, the paroxysms shall have abated in their vio- 
lence, but still continue to return, so as to occasion 
painful and restless nights, opiates may then be given 
with safety and advantage, .especially in the case of per- 
sons advanced in life, and who have been often affected 
with the disease. 

570. When, after paroxysms have ceased, some swell- 
ing and stiffness shall remain in the joints, these symp- 
toms are to be discussed by the diligent use of the 
flesh-brush. 

571. Purging, immediately after a paroxysm, will be 
always employed with the hazard of bringing it on 
again, f 

572. I have now finished what has occurred to be 
said upon the means of preventing and curing the regu- 

* As far as our own observation has enabled us to decide, we consider all 
active topical applications, in cases of podagra, somewhat hazardous; and are, 
therefore, inclined to caution practitioners against their use We believe, 
with our author, that soft flannel, or flakes of carded wool, or cotton, consti- 
tute the best remedies of this description. In atonic gout, the same objec- 
tions against topical applications do not exist. In that complaint, when in the 
form of lumbago, sciatica, or pains in the joints, blisters, sinapisms, and 
other external irritating means, judiciously directed, are exceedingly useful. 

f This we believe to be an error. We have never witm-ssi-d the event 
in practice ; nor do we know of any principle on which it could be explained. 



PRACTICE OF PHYSIC. 35} 

lar gout; and shall now consider its management when 
it has become irregular; of which, as I have observed 
above, there are three different cases. 

573. In the first case, which I have named the Ato- 
nic Gout, the cure is to be accomplished by carefully 
avoiding all debilitating causes; and by employing, at 
the same time, the means of strengthening the system 
in general, and the stomach in particular. 

574. For the avoiding debilitating causes, I must re- 
fer to the doctrines of the Hygieine, as in 553. 

575. For strengthening the system in general, I must 
recommend frequent exercise on horseback, and mode- 
rate walking. Cold bathing also may answer the pur- 
pose, and may be safely employed if it appear to be pow r 
erful in stimulating the system, and be not applied when 
the extremities are threatened with any pain. 

For supporting the tone of the system in general, 
when threatened with atonic gout, some animal food 
ought to be employed, and the more acescent vegeta- 
bles ought to be avoided. In the same case, some wine 
also may be necessary, but it should be in moderate 
quantity, and of the least acescent kinds; and, if every 
kind of wine shall be found to increase the acidity of 
the stomach, ardent spirits and water must be em- 
ployed.* 

576. For strengthening the stomach, bitters and the 
Peruvian bark may be employed; but care must be 
taken that they be not constantly employed for any great 
length of time. Compare 556. 

The most effectual medicine for strengthening the 
stomach is iron, which may be employed under various 

* Persons subject to atonic gout should approach the cold bath with great 
caut.on. If, on being used, it excite on the surface of the body and extreme 
ties, a pleasant glow, it may be safely continued; but, if it produce a sensa- 
tion of chilliness, let it be promptly abandoned. 



352 PRACTICE OF PHYSIC. 

preparations ; but, to me, the best appears to be the rust 
in fine powder, which may be given in very large doses. 

For supporting the tone of the stomach, aromatics 
may be employed; but should be used with caution, as 
the frequent and large use of them may have an oppo- 
site effect; and they should therefore be given only in 
compliance with former habits, or for palliating present 
symptoms. 

When the stomach happens to be liable to indiges- 
tion, gentle vomits may be frequently given; and proper 
laxatives should be always employed to obviate, or to 
remove costiveness.* 

577. In the atonic gout, or in persons liable to it, to 
guard against cold is especially necessary; and the most 
certain means of doing this is, by repairing to a warm 
climate during the winter season. 

578. In the more violent cases of the atonic gout, 
blistering the lower extremities may be useful; but that 
remedy should be avoided when any pain threatens the 
extremities. In persons liable to the atonic gout, issues 
may be established in the extremities, as, in some mea- 
sure, a supplement to the disease. f 

579. A second case of the irregular gout, is that 
which I have named the Retrocedent When this af- 
fects the stomach and intestines, relief is to be instantly 

* Besides acting - with superior efficacy, prepared steel is much less apt to 
disorder the stomach, if it be combined witli a small quantity of powdered 
ginger, cinnamon, cloves, or some other warm and pleasant aromatic. Of 
prepared steel, ten grains may be administered from three to six times a-dny, 
according to the exigency of the case, and the retentive power of the 
stomach. 

Suitable purges for arthritic patients are, magnesia, rhubarb, gum guaia- 
cum, or an infusion of senna, rendered aromatic by cardamum, or fennel 
seeds. 

-j- In Cases of this description, the application of sinapisms is greatly pre- 
ferable to that of blisters. The establishment of issues in the extremities, 
we consider a hazardous experiment, as the consequence may be, the pro 
duction of troublesome sores. 



PRACTICE OF PHYSIC. 353 

attempted by the free use of strong wines, joined with 
aromatics, and given warm; or if these should not prove 
powerful enough, ardent spirits must be employed, and 
are to be given in a large dose. In moderate attacks, 
ardent spirits, impregnated with garlic, or with asafce- 
tida, may be employed; or, even without the ardent 
spirits, a solution of asafcetida with the volatile alkali 
maj answer the purpose. Opiates are often an effec- 
tual remedy, and may be joined with aromatics, as in 
the Electuarium Thebaicum; or they may be usefully 
joined with volatile alkali and camphire. Musk has 
Jikevvise proved useful in this disease, 

When the affection of the stomach is accompanied 
with vomiting, this may be encouraged, by taking 
draughts of warm wine, at first with water, and after- 
wards without it; having at length recourse, if necessary, 
to some of the remedies above-mentioned, and particu- 
larly to the opiates. 

In like manner, if the intestines be affected with diar- 
rhoea, this is to be at first encouraged, by taking plenti- 
fully of weak broth; and when this shall have been done 
sufficiently, the tumult is to be quieted by opiates.* 

580. When the retrocedent gout shall affect the lungs, 
and produce asthma, this is to be cured by opiates, by 
antispasmodics, and perhaps, by blistering on the breast 
or back.f 

* In a case like this, opiates may be given in very powerful and repeated 
doses An ounce of laudanum has been administered in the space of eight 
hours, w'nh safely and success. If the spasm be violent, eiiher may be, ex- 
hibited with particular advantage. So may a very strong tincture of assafce- 
tid i, jarlic or camphor. 

We know not on what principle wine should be given to promote vomit- 
ing in retrocedent gout Warm water is greatly preferable. 

fin the treatment of this form of retrocedent goin, emetics are exhibited 
with the happiest effect. Cupping on the breast, or along the spine oppo- 
site to the thorax, is also useful Our author is correct in his opinion of 
blistering. It constitutes, here, an important remedy. So do stimulating 
applications to the extremities. 



VOL, I. 



yy 



354 PRACTICE OF PHYSIC. 

581. When the gout, leaving the extremities, shall 
affect the head, and produce pain, vertigo, apoplexy, 
or palsy, our resources are very precarious. The most 
probable means of relief is, blistering the head: and if 
the gout shall have receded entirely from the extremi- 
ties, blisters may be applied to these also. Together 
with these blisterings, aromatics, and the volatile alkali, 
may be thrown into the stomach.* 

582. The third case of the irregular gout is what I 
have named the Misplaced; that is, when the inflamma- 
tory affection of the gout, instead of falling upon the 
extremities, falls upon some internal part. In this case, 
the disease is to be treated by blood-letting, and by 
such other remedies as would be proper in an idiopa- 
thic inflammation of the same parts. 

583. Whether the translation so frequently made 
from the extremities to the kidneys, is to be consider- 
ed as an instance of the misplaced gout, seems, as we 
have said before, uncertain; but I am disposed to think 
it something different; and therefore am of opinion, 
that, in the Nephralgia Calculosa produced upon this 
occasion, the remedies of inflammation are to be em- 
ployed no farther than they may be otherwise some- 
times necessary in that disease, arising from other 
causes than the gout. 

• In this form of the disease, copious purging, with the application of 
cups to the temples, and also venesection, if the system will hear it, are re- 
medies of fair promise, and ought not to be omitted. The application of 
blisters to the ankles, and sinapisms to the feet, may also be practised with 
the prospect of advantage. In every case of gout, whether atonic or retro- 
cedent, it is correct practice to endeavour, by irritating applications, to fix 
it in the extremities— the hands or feet, according to its tendencies. 



PRACTICE OF PHYSIC. S5n 



BOOK III. 

OF EXANTHEMATA, 

OR ERUPTIVE FEVERS 



584. THE diseases comprehended under this title, 
which make the third Order of Pyrexias in our Noso- 
logy, are In general such as do not arise but upon oc- 
casion of a specific contagion applied, which first pro- 
duces fever, and afterwards an eruption upon the sur- 
face of the body; and which diseases, for the most part, 
affect persons but once in the course of their lives.* 

5S5. Whether the character of the Order may be 
thus limited, or if the Order may be allowed to com- 
prehend also the eruptive fevers produced by a matter 
generated in the body itself, and likewise those cases 
of eruption which do not depend upon contagion, or 
upon a matter generated before the fever, but upon a 

* We shall, hereafter, say more particularly, that Pestis vera, or true 
Plague, is very improperly referred to the order exanthemata. It is not an 
eruptive disease; but belongs, of right, to the order febres ; or rather, per- 
haps, to that of phlegmasia; in as much as it is usually marked by some in- 
flammatory affection, particularly an inflammation of the stomach. The hu- 
man body, moreover, is liable to be attacked by it more than once. We do 
not believe that either it or scarlet fever is, strictly speaking, a contagious 
disease. 

We feel persuaded, that all the exanthemata are original diseases of the 
stomach : we mean, that they originate in a topical affection of that organ. 

Having never seen a case of oriental plague, we no not feel authorized to 
speak of the treatment of that disease. 



356 PRACTICE OF PHYSIC, 

matter generated in the course of ihc fever, 1 am not 
ready to determine. Of the diseases enumerated by 
the Nomologists as Exanthemata, there are certainly 
three different kinds, which may be distinguished by 
the circumstances mentioned in this and the preceding 
paragraph. Of the first kind are the Small-Pox, the 
Chicken-Pox, the Measles, the Scarlet Fever, and the 
Plague. Of the second kind seems to be the Erysipe- 
las; and of the third kind I judge the Miliaria and Pe- 
techia to be. But as I am not sufficiently confident in 
the facts which should support these distinctions, or 
which would enable us to apply them in all cases, I go 
on in this book to treat of almost all the exanthemata 
enumerated by preceding Nosologists, with only some 
difference in the arrangement from what it was in my 
former editions. 



CHArTER t. 
OF THE SMALL POX.* 

586. THE small pox is a disease arising from a con- 
tagion of a specific nature, which first produces a fever; 

* For manv years past, the attention of physicians, both in Europe and 
America, has been directed, not to the making 1 of improvements in the treat* 
ment of casual small-pox, but, first, to the mitigation of that disease by the 
practice of inoculation ; and, ultimately, to its entire prevention, by substi- 
tuting' in its place, the variolae vaccina;, or cow-pox. 

As we hope, that even inoculation will never hereafter be practised in 
anv part of the world, we should deem it superfluous to engross the time 
of our readers by any particular directions respecting it — much less do we 
think it our duty to trouble them with additions to what our author has said 
on the subject of the casual, or, as it is usually denominated, the natural 
small-pox. Instead of this, it will be much more useful, as we conceive, and 
will certainly better accord with the present state of medicine, to invite 
their attention to an account of the cow-pox. This we shall do, in the shape 



PRACTICE OF PHYSIC. 357 

and on the third or. fourth day thereof, produces an 
eruption of small red pimples. These are afterwards 

of a note, as it would be wrong to interpolate, in any way, the text of our 
author. 

On looking over the article "Vauiolb Yaccix.e, on Cow-Pox," in Tho- 
mas's " Modern Practice of Physic," we find it to be sensible and well com- 
posed — much compressed, indeed, yet containing almost everything neces- 
sary to be known in relation to that disease. We shall, therefore, insert it 
here, precisely as it stands, prefacing it with the following brief remarks. 

Our own experience in relation to the comparative force of the poisons 
of small. pnx and cow-pox, is somewhat different from that of Dr. Thomas. 

Soon after the introduction of the latter disease into the city of Philadel- 
phia, we inserted those two poisons into the different arms of the same in- 
dividual — a boy about twelve years old. The experiment with each virus 
succeeded so far as to produce a topical affection ; and the two affections in- 
creased, pari passu, until about the eighth day. At this period, however, a 
very striking difference ensued. The vaccine pock assumed completely its 
characteristic appearance, and took possession of the system in the form of 
a general disease ; while the variolous pock ceased to make any further 
progress in growth, and, in a few days, withered and disappeared, without 
suppurating, or producing the slightest affection of the system. 

This is the only experiment we made Circumstances, at the time, pre- 
vented us from repeating it ; and the efficacy of the vaccine, as a preventive 
of the variolous disease, being - soon afterwards established to our satisfac- 
tion, we did not feel it necessary to return to the subject. 

It is found in this country, and the fact is now, we believe, known and ac- 
knowledged in Europe, that the virus of the cow-pox can be preserved with 
more certainty, for a much longer time, and in better condition, in a dry 
than in a humid state. We vaccinate, therefore, with the scab, when per- 
fectly desiccated, rather than with the matter taken from the pock in a fluid 
form. Thus fixed and secured from the effects of both fermentation and 
evaporation, the virus may be conveyed to almost any distance, and the dis- 
ease propagated in the remotest parts of the world. 

A scab, with the cuticle entire, small, perfectly circular, of a dark maho- 
gany colour, and somewhat rough on the external surface, is found to be 
most richly imbued with the poison, and to retain it longest in an active con- 
dition. 

Unless in cases where it has been improperly irritated, by accident, or in- 
tentional scratching, the affection of the arm, in the cow-pox, has never 
provecr%i the slightest degree troublesome to us. 

This disease may be propagated with equal advantage at every season of 
the year, except that, during the severities of winter, and the intense heats 
of summer, when the skin is strongly stimulated by heat and cold, it cannot 
he communicated with the same facility as during the milder weather of the 
autumn and spring. 

It is often stated, as a question, why an inoculated disease is less severe 



358 PRACTICE OF PHYSIC. 

formed into pustules, containing a matter, which, in the 
course of eight days from the time of the eruption, is 

than cne contracted casually ? or, as it is usually expressed, in the natural 
way ? \ 

To us, the answer has always appeared to be plain and easy. 

The strength and severity of a disease are proportioned to the importance 
and the sympathies of the organ in which it has its seat. On this account, 
diseases that are sealed in the stomach, are more violent than those which 
are radicated in the skin. This, we consider, as amounting to a solution of 
the question we are considering. 

An inoculated disease — small-pox, for example — has its origin in the skin, 
and affects the stomach secondarily and slightly: but the casual small-pox 
takes root in the stomach, and produces in that organ a much more power- 
ful and serious affection. Hence the violence and danger of the disease 
that follows. 

Thus, the passage of a ball or a bayonet through the muscles of the 
thigh, gives rise, to a wound which is rarely fatal ; while the same weapon, by 
passing through the stomach or the intestines, produces a disease which is 
seldom cured. 

VARIOUE VACCINA, Oil COW-POX. 

In many of the dairy counties it has been long known that the cows are 
liable to an eruption on their paps or udders, which was occasionally com- 
municated to the hands or arms of those who milked them, producing an 
ulcer, and some degree of fever; and it had been observed by the people of 
those counties, that those who had undergone this disease, known by the 
name of cow-pox, were not liable to the small-pox. 

The disease had not, however, undergone any medical investigation until 
l)r. Jenner, then of Berkley, in Gloucestershire, paid particular attention to 
it. He very satisfactorily ascertained that it was a much milder disease than 
the small-pox, and that the fact was true, that it secured those who had been 
infected with it from afterwards being liable to variolous infection. He also 
observed that the vaccine-pox is not infectious, but by inoculation ; and that 
on this account it might be inoculated in a family without endangering 
others; a circumstance of the greatest importance. On the suggestions of 
Dr. Jenner, many practitioners were induced to adopt the practice of sub- 
stituting the one disease for the other, and its efficacy is now fully esta- 
blished. 

With respect to the origin of the disease in the cow, we are informed by 
Dr. Jenner, that he traced it to the diseased heels of horses which had been 
affected with the grease ; and by the person appointed to apply the dress- 
ings to them, not paying a due attention to cleanliness, and incautiously bear- 
ing his part in milking the cows, with some particles of the infectious mat- 
ter adhering to his fingers, he has communicated the disease to them. From 
numerous experiments made, however, at an early period, by the late Dr. 
Woodville, and by Mr. Coleman, Professor at the Veterinary College, with 



PRACTICE OF PHYSIC. 359 

changed into pus. After this, the matter dries, and falls 
off in crusts. 

the matter of grease, taken in the various stages of that complaint, no such 
effect has been produced upon cows. Neither were inoculations with this 
matter, nor with several other morbid secretions in the horse, productive of 
any effects upon the human subject, which by no means accord with the 
tacts adduced by Dr. Jenner on this point. 

Some communications through the medium of the Medical and Physical 
Journal (see vol. iv. pages 381 and 466,) in consequence of still later expe- 
riments, seem however to give support to Dr. Jenner's opinion as to the 
origin of the disease. 

On its first investigation, some circumstances led to the supposition that 
the cow-pox and the small-pox were originally one and the same disease; 
the latter being derived from the animal at some remote period, and having 
undergone in the lapse of years, and by the influence of various constitu- 
tions, the changes we now experience. Subsequent facts have, however, 
invalidated this opinion. 

From various experiments it appears that the vaccine disease and the 
small-pox are not susceptible of intermixture, but that each preserves its 
distinct character under all circumstances. At the Small-pox Hospital it 
has been noticed, that when the vaccine and variolous fluids are mixed to- 
gether, and thus inserted, sometimes the vaccine pustule, at others the vari- 
olous, has been produced, each of them retaining its characteristic marks 
throughout. Again, it has been found, that when the two fluids are insert- 
ed separately, and so near together, that the two pustules which follow 
spread into one, by inoculating with the fluid taken from one side of it, the 
vaccine pustule alone will be produced, while the fluid taken from the other 
excites the genuine variolous pustule, with the general eruption of small- 
pox on the body. Another point of dissimilarity between the variolous and 
vaccine diseases is this : the inoculation of the former we well know super- 
sedes the natural disease many days after exposure to infection. 

The effect produced by submitting persons to the influence of* variolous 
and vaccine matter at the same time, is, that they both prove effective ; for 
the vaccine vesicle proceeds to its acme in the usual number of days, and 
the maturation of the variolous pustules is attended with a pustular eruption 
on different parts of the body ; but when variolous matter is not inserted 
untd the ninth day after the inoculation with vaccine matter, the action of 
the variolous seems to be wholly precluded. 

The variolous and vaccine fluids inoculated about the same time, restrain 
the action of each other. The vaccine vesicle, in this case, is smaller, and 
proceeds more slowly to its maturity; and the variolous pustules are small, 
hard, and shining, producing only a small particle of matter at their apices. 
The nipples of the cow being once affected, the disorder is communi- 
cated to the dairy -maids, and other assistants employed in milking, and by 
them it is spread through the farm, till at last most of the cattle experience 
its consequences. 



360 PRACTICE OF PHYSIC. 

587. This is a general idea of the disease: hut there 
are two particular forms or varieties of it, well known 

The disease appears on the nipples of the cows in the form of irregular 
pustules, which on their first appearance are commonly of a colour some- 
what approaching to livid, and are surrounded by an erysipelatous inflam- 
mation, according to the report of Dr. Jenner; but Dr. Woudville seems to 
think that it is rather an indurated tumefaction of the skin which surrounds 
the pustules, than an inflammation of an erysipelatous nature. Unless pro- 
per remedies are applied in time, these pustules soon degenerate into pha- 
gedenic ulcers, which prove extremely troublesome ; the animals then be- 
come much indisposed, and the secretion of milk suffers a considerable di- 
minution. 

Inflamed spots now begin to appear on different parts of the hands and 
wrists of the domestics employed in milking, which run on quickly to sup- 
puration, assuming at first the appearance of small vesications produced by 
a burn. Most commonly they come out about the joints of the fingers, and 
at their extremities; but whatever parts are affected, if the situation will 
admit, these superficial suppurations put on a circular form, with their edges 
more elevated than their centre-, and of a colour distinctly approaching to 
blue In consequence of absorption, tumours appear in each axdla, the 
system becomes affected, the pulse is quickened, and rigours, with general 
lassitude and pains about the limbs and loins, with a vomiting, come on. In 
some instances, the head is much affected, and a delirium arises. 

These symptoms varying in their degrees of violence, usually continue 
for three or four days, leaving ulcerated sores about the hands, which from 
the sensibility of the parts are very troublesome, and commonly h^al slowly, 
becoming not unfrequently phagedenic, like those from which they sprung. 

The lips, nostrils, eye-lids, and other parts of the body, are likewise af- 
fected sometimes with sores, in consequence of being heedlessly rubbed or 
scratched with the patient's infected fingers. 

Dr. Jenner informs us that he had never met with any case of the cow- 
pox, either taken naturally, or produced artificially, which proved fatal ; but 
by Dr. Woodville we are told, that out of five hundred cases of inoculated 
cow-pox under his care, one proved fatal, which was a child at the breast, 
on the eleventh day after the matter had been inserted in the arm 

From that occurrence, and a few cases in which the febrile symptoms ran 
high, this gentleman was at first very adverse to the vaccine inoculation ; but 
from further trials he latterly gave it, with almost every other practitioner, 
the most decided preference. 

The few instances of death which have occurred from vaccine inoculation, 
since it has been more generally practised, may probably be referred with 
much justice to some unknown peculiarities of the constitution ; to inter- 
vening disorders independent of the vaccine, and to inflammation excited 
by accidental causes in young children, especially when they have been ill 
fed and badly nursed — circumstances not uncommon among very poor 
people. 

"When the pustules are numerous, as sometimes happens where the dis- 



PRACTICE OF PHYSIC. 361 

under the appellations of the Distinct and Confluent, 
which require to be specially described. 



ease has been received immediately from the cow, a considerable degree of 
fever attends ; bnt when it has arisen from inoculation, few or no pustules 
are to be observed, except immediately round the wound in the arm ; and 
little or no inconvenience is experienced. 

A more general knowledge of the disease, than what we had at first, has 
ascertained it to be an undoubted fact, that the vaccine virus is greatly mo- 
dified, and rendered much milder by passing through different habits; and 
that although the cow-pox has proved in many instances a severe disorder 
in those who received the infection immediately from the animal, still, in a 
few instances only, have the' symptoms run high, or has the least inconve- 
nience been experienced, where proper matter taken from the human sub- 
ject was used for inoculation. 

in the few cases which have been brought forward, where a numerous 
eruption, proceeded by a fiery redness, took place, we should attribute it 
to something wrong in the habit of body ; to the intervening of some other 
eruptive disease ; or possibly to the having inoculated with matter which 
had undergone a decomposition, in consequence of putrefaction, or some 
other cause not obvious. 

A use of medicine seems wholly unnecessary in the cow-pox, except in 
those cases of the natural disease where much febrile heat attends; and 
then the antiphlogistic plan ought to be pursued. 

The vaccine virus is certainly of a very singular nature, in as much as that 
a person who has been infected by it, is found to be for ever after secure 
from the infection of the small-pox ; neither exposure to variolous effluvia, 
nor the insertion of the matter into the skin, being capable of producing 
the disease. Many direct experiments made by innumerable practitioners, 
prove that the susceptibility of the small-pox is totally destroyed by inocu- 
lating with the vaccine matter. The permanency of the effect was indeed 
a matter of some doubt, but that is now fully established. It appears from 
the report of the Small-pox Hospital in London, that up to December 1802, 
eleven thousand eight hundred patients and upwards had been vaccinated, 
of which number twenty-five hundred were afterwards proved to be secured 
from the natural small-pox, by receiving a further inoculation with small-pox 
matter, while they were at the same time exposed in an hospital full of its 
infection, without effect. It was said at first, that although the cow-pox de- 
stroyed the susceptibility of the small-pox, still it possessed not the same 
power with regard to itself, as a person might have the disease more than 
once. Instances certainly have been adduced of the cow-pox taking place 
a second time ; but they are of very rare occurrence, and should be looked 
on as irregular. The same has happened with the small-pox. 

In Dr. Jenner's first treatise, he mentions that the small pox is not always 
a security against the cow-pox, and that although the susceptibility of the 
virus of the cow-pox is for the most part lost in those who have had the 
VOL. I. Z Z 



362 PRACTICE OF PHYSK 

588. In the former, or in the distinct small-pox, the 
eruptive fever is moderate, and appears to be evidently 



small-pox, yet in some constitutions it is only partially destroyed, and in 
others it does not appear to be in the least diminished. A more intimatt 
knowledge of the disease has convinced us of the fallacy of this opinion. 

Soon after Dr. Jenner's first publication on the vaccine disease, a few in- 
stances were adduced, tending to invalidate his supposition of the preven- 
tive power of the cow-pox with regard to variolous infection ; but these he 
considers to have been cases of a spurious disease, and therefore not affect- 
ing his general conclusion. 

In using this term, he does not mean, however, to imply that there is a 
true and false cow-pox, but merely to express an irregularity or difference 
from that common form and progress of the vaccine pustule from which its 
efficacy is inferred. Those who perform vaccination ought, therefore, to be 
■well instructed, and should have watched with the greatest care the regular 
process of the pustule, and learned the most proper time for taking the 
matter. 

A few cases of still later occurrence have also been brought forward by 
Mr. Goldson* of Portsmouth, and others, with a view of proving that the in- 
oculated cow-pox is not a permanent security against the infection of the 
small-pox ; but a failure in one or two cases out of more than thirty thousand, 
although ever so well substantiated, should be considered in no other light 
than as a casual irregularity, upon which no solid determination can, or 
ought to be grounded. Instances of the like nature have been known to 
occur likewise among persons inoculated with variolous matter, and when 
they are met with, ought to be looked on as anomalous. 

There can be little doubt, however, that some of the failures are to be 
imputed to the inexperience of the early vaccinators, and it is by no means 
unreasonable to expect that further observation will yet suggest many im- 
provements that will reduce the number of anomalous cases, and furnish the 
means of determining with greater precision when the vaccine disease has 
been effectually received. 

Persons who have been vaccinated, and passed through the cow-pox with 
all the usual accompanying symptoms, and who have afterwards taken the 
small-pox, of which a very few instances may have happened, have generally 
imperfect pustules, which die away, in a few days, without exciting any con- 
stitutional complaint; but the matter taken from these pustules will com- 
municate the small-pox. This circumstance has been brought forward by 
the anti-vaccinists as a proof that persons who have had the cow-pox, may 
afterwards take the small-pox by inoculation, and otherwise, not making 
the proper distinction between local and constitutional infection; or per- 
haps not understanding how any one can communicate a disease to others, 
with which he is not himself infected. 

* See his cases of Small-pox subsequent to Vaccination. 



PRACTICE OF PHYSIC. 363 

of the inflammatory kind, or what we name a Synocha. 
It generally comes on about mid-day, with some symp- 

We are informed by Dr. Jenner that the sources of a spurious cow-pock 
are as follow : 

1st, That arising from pustules on the nipples ov udder of the cow ; 
which pustules contain no specific virus. 

2dly, From the matter (although originally possessing the specific virus) 
which has suffered a decomposition either from putrefaction, or from any 
other cause less obvious to the senses. 

odly, When the matter is taken from an ulcer in an advanced stage, which 
ulcer arose from a true cow-pock : and, 

4thly, He supposes a spurious disease to arise from matter produced on 
the human skin, from contact with some peculiar morbid matter generated 
by a horse. 

The characteristics of the true cow-pox are as follow, viz a circumscribed, 
circular, elevated eruption, surrounded by a red halo or efflorescence, 
smooth surface ; brown, black, or mahogany, and tamarind-stone coloured, 
long adhering scab. 

From a chemical analysis of vaccine matter by some French physicians, it 
was found to consist of water and albumen. 

The succeeding arguments have been urged in favour of inoculation for 
the cow-pock over that for the small-pox. 

1st, Of several thousand persons who have had the inoculated cow-pock, 
only one or two have died. 

2dly, Very few well attested instances have been produced out-of many 
thousands of the above persons, known to have had the inoculated vaccine 
pock, and who were subsequently inoculated for the small-pox, of this dis- 
ease being afterwards taken ; although many of these were also exposed to 
the infectious effluvia of the natural small-pox. And, traditionally, this fact 
has been established time immemorial, with regard to the casual cow-pox. 

odly, It may safely be affirmed, that the inoculated cow-pock is generally 
a much slighter disease than the inoculated smallpox ; and that the propoi- 
tion of severe cases in the latter is to the former as at least ten to one. 

4thly, It does not appear that the genuine vaccine pock can be propagated 
like the small-pox, by effluvia from persons labouring under it. Hence, if 
the vaccine inoculation should be universally instituted in place of the small- 
pox, it is reasonable to conclude, that this most loathsome and fatal malady 
will be extinguished. 

5thly, It does not appear that the vaccine poison, like that of the small-po.x, 
can be conveyed so as to produce the, disease indirectly from diseased per- 
sons, by adhering to clothes, furniture, bedding, letters, &c. Hence, no 
danger of its propagation in these channels is to be apprehended from the 
universal practice of the inoculation of the cow-pock. 

6thly, It has been found, that a person whose constitution has distinctly 
undergone the vaccine disease, is in future unsusceptible of the same dis- 
order. Hence no objection can be made to the new inoculation, as was 
once urged, on account of its being believed, that by the commutation of the 



364 PRACTICE OF PHYSIC. 

toms of a cold stage, and commonly with a considerable 
languor and drowsiness. A hot stage is soon formed, 

small pox for the vaccine pock, an eruptive disease would be introduced, to 
which the same person would be repeatedly liable. 

7thly, It does not appear that those who have already gone through the 
small-pox, are susceptible of the vaccine disease as was at first believed. 
Hence no objection can be urged on the score of persons who have already 
g'me through the small-pox, being liable to a new infectious disease, by the 
introduction of the vaccine inoculation. 

8 hly, Experience shows, that there is no reason to apprehend the small- 
est chance of deformities ol the skin from the vaccine inoculation. 

9thly, The extensive practice of the vaccine inoculation, and the accounts 
of the disease in the casual way, do not show that any other disease will be 
excited subsequently, which is peculiarly imputable to the new practice. 

On a review of these arguments founded on facts, there can remain no 
doubt but thai the vaccine inoculation will soon wholly supersede and do 
away the variolous. Could all parents be persuaded to inoculate their 
children with vaccine matter soon after birth, the small-pox might be 
entirely eradicated in time. The introduction of this species of inoculation 
generally throughout both the army and navy, and its extension to France, 
Spain, Germany, and every part of the continent, as well as to both the In- 
dies, fully stamp its value and efficacy, and give us reason to hope that it will 
shortly be adopted by every nation of the earth with whom we have the 
least communication. Vaccination has indeed penetrated to the remotest 
corners of the globe, and wherever it has been introduced, the increasing 
experience of every 'year has only served to confirm pretty generally a con- 
fidence in its efficacy. It has been recommended and adopted by far the 
greatest and most respectable part of the profession, every where ; but, by a 
few individuals, it has been obstinately opposed through interested motives. 

In inoculating for the vaccine disease, we should carefully attend to the 
following circumstances. 

1st, That the matter should not be taken later than the ninth day of the 
disease. 

2dly, That the fluid should be perfectly transparent, as it is not to be de- 
pended upon, if it has become in any degree opaque. 

3dly, That the matter, if not used immediately, should be allowed to dry 
gradually and thoroughly before it is laid by for future use. 

4thly, That the punctures can scarcely be made too superficial, and on no 
account should more than one be made in each arm. 

5thly, That attention should be made to repress, as soon as may be, any 
excess of inflammation that may happen to arise; and this is best done by 
cold and restringent applications. 

From the report of the physicians of the Vaccine Pock Institution, it ap- 
pears that the matter of a single pustule, being mixed with one quarter of 
an ounce measure of warm water, such diluted matter excited as distinct a 
vaccine pock by inoculation, as an equal quantity of undiluted matter. A 
pock so excited, was not attended with less inflammation, or constitutional 



PRACTICE OF PHYSIC. 365 

and becomes more considerable on the second and third 
days. During this course, children are liable to frequent 
startings from their slumbers; and adults, if they arc 
kept a-bed, are disposed to much sweating. On the third 
day, children are sometimes affected with one or two 
epileptic fits. Towards the end of the third day, the 
eruption commonly appears, and gradually increases 
during the fourth; appearing first upon the face, and 
successively on the inferior parts, so as to be completed 
over the whole body on the fifth day. 

From the third day, the fever abates; and against the 
fifth, it entirely ceases. The eruption appears first in 
small red spots, hardly eminent, but by degrees rising 
into pimples. These are generally upon the face in small 
number; but even when more numerous, they are sepa- 
rate and distinct from one another. On the fifth, or 
sixth day, a small vesicle, containing an almost colour- 
less or whey-coloured fluid, appears upon the top of each 
pimple. For two days, these vesicles increase in breadth 
only, and there is a small hollow pit in their middle; so 
that it is only against the eighth day that they are raised 
into spheroidical pustules. 

These vesicles or pustules, from their first formation, 
continue to be surrounded with an exactly circular in- 
flamed margin, which, when the pustules are numerous, 
diffuses some inflammation over the neighbouring skin, 
so as to give somewhat of a damask rose colour to the 
spaces between the pustules. As the pustles increase 
in size, if they be numerous on the face, against the 
eighth day the whole of the face becomes considerably 
swelled: and, in particular, the eye-lids are so much 
swelled as entirely to shut the eyes. 

affection, than that excited by a larger quantity of undiluted matter; which 
points out an easy method of inoculating several persons from a single vac- 
cine pock— a great conveniency indeed, when the poor to be inoculated at 
one time are very numerous. 



36G PRACTICE OF PHYSIC. 

As the disease thus proceeds, the matter in the pus- 
tules becomes by degrees more opaque and white, and 
at length of a yellowish colour. On the eleventh day, 
the swelling of the face is abated, and the pustules 
seem quite full. On the top of each a darker spot ap- 
pears; and at this place the pustule, on the eleventh 
day, or soon after, is spontaneously broken, and a por- 
tion of the matter oozes out: in consequence of which 
the pustule is shrivelled, and subsides; while the mat- 
ter oozing out dries, and forms a crust upon its sur- 
face. Sometimes a little only of the matter oozes out; 
and what remains in the pustule becomes thick, and 
even hard. After some days, both the crusts and the 
hardened pustules fall off, leaving the skin, which they 
covered, of a brown red colour; and it is only after 
many days that the skin in these places resumes its na- 
tural colour. In some cases, where the matter of the 
pustules has been more liquid, the crusts formed by it 
are later in falling off", and the part they covered suffers 
some desquamation, which leaves in it a small pit or 
hollow. 

This is the course of things on the face; and succes- 
sively, the pustules on the rest of the body take the 
same. The matter of the pustules, on the arms and 
hands, is frequently absorbed; so that, at the height of 
the disease, these pustules appear as empty vesicles. 
On the tenth and eleventh days, as the swelling of the 
face subsides, a swelling arises in the hands and feet; 
but which, again, subsides, as the pustules come to ma- 
turity. 

When the pustules on the face are numerous, some 
degree of pyrexia appears on the tenth and eleventh 
days, but disappears again after the pustules are fully 
ripened; or perhaps remains in a very slight degree till 
the pustules on the feet have finished their course. It 



PRACTICE OF PHYSIC. 367 

is seldom that in the distinct small-pox the fever con- 
tinues longer. 

When the pustules on the face are numerous, some 
uneasiness in the throat, with a hoarseness of the voice, 
comes on upon the sixth or seventh day, and a thin li- 
quid is poured out from the mouth. These symptoms 
increase with the swelling of the face; and the liquids 
of the mouth and throat becoming thicker, are more 
difficultly thrown out. There is at the same time some 
difficulty of swallowing; so that liquids taken in to be 
swallowed are frequently rejected, or thrown out by 
the nose. But all these affections of the fauces abate 
as the swelling of the face subsides. 

589. In the other form of small-pox, or what is call- 
ed the Confluent, the course of the disease is, in gene- 
ral, the same with that we have described; but the 
symptoms of every stage are more violent, and several 
of the circumstances are different. 

In particular, the eruptive fever is more violent. 
The pulse is more frequent and more contracted, ap- 
proaching to that state of pulse which is found in the 
typhus. The coma is more considerable, and there is 
frequently a delirium. Vomiting also is a common 
symptom, especially at the coming on of the disease. 
In very young infants, epileptic fits are sometimes fre- 
quent on the first days of the disease, and sometimes 
prove fatal before any eruption appears; or they usher 
in a very confluent and putrid small-pox. 

590. The eruption appears more early on the third 
day, and it is frequently preceded or accompanied with 
an erysipelatous efflorescence. Sometimes the erup- 
tion appears in clusters, like that of the measles. When 
the eruption is completed, the pimples are always more 
numerous upon the face, and at the same time smaller 
and less eminent. After the eruption, the fever suffers 



368 PRACTICE OF PHYSIC. 

some remission, but never goes off entirely; and after 
the fifth or sixth day it again increases, and continues 
considerable through the remaining course of" the dis- 
ease. 

The vesicles formed on the tops of the pimples ap- 
pear sooner; and while they increase in breadth, do not 
retain a circular, but are every way of an irregular 
figure. Many of them run into one another, insomuch, 
that very often the face is covered rather with one ve- 
sicle than with a number of pustules. The vesicles, so 
far as they are any wise separated, do not arise to a 
spheroidical form, but remain flat, and sometimes the 
whole of the face is of an even surface. When the 
pustules are in any measure separated, their circumfer- 
ence is not bounded by an inflamed margin, and the 
part of the skin that is free from pustules is commonly 
pale and flaccid. 

The liquor that is in the pustules changes from a 
clear to an opaque appearance, and becomes whitish 
or brownish, but never acquires the yellow colour and 
thick consistence that appear in the distinct small-pox. 

591. The swelling of the face which attends the dis- 
tinct small-pox, when they are numerous., and almost 
then only, always attends the confluent, comes on more 
early, and arises to a greater degree; but abates on the 
tenth day, and on the eleventh still more. At this time 
the pustules or vesicles break, and, shrivelling, pour 
out a liquor that is formed into brown or black crusts, 
which do not fall off for many days after. Those of 
the face, in falling off, leave the parts they cover sub- 
ject to a desquamation, which pretty certainly produces 
pittings. 

On the other parts of the body, the pustules of the 
confluent small-pox are more distinct than upon the 



PRACTICE OF PHYSIC. 369 

face, but never acquire the same maturity and consist- 
ence of pus, as in the properly distinct kind. 

The salivation, which only sometimes attends the dis- 
tinct small-pox, very constantly attends the confluent; 
and both the salivation and the affection of the fauces 
above mentioned, are, especially in adults, in a higher 
degree. In infants, a diarrhoea comes frequently in 
place of the salivation. 

In the confluent small-pox, there is often a consider- 
able putrescency of the fluids, as appears from pete^ 
chiae, from serous vesicles, under which the skin shows 
a disposition to gangrene, and from bloody urine, or 
other hcemorrhagy, all which symptoms frequently ac- 
company this disease. 

In the confluent small-pox, the fever, which had only 
suffered a remission from the time of eruption to that 
of maturation, is often, at or immediately after this pe- 
riod, renewed with considerable violence. This is 
what has been called the Secondary Fever; and is, in 
different cases, of various duration and event. 

592. We have thus endeavoured to describe the va- 
rious circumstances of the small-pox; and from the dif- 
ference of these circumstances, the event of the dis- 
ease may be determined. The whole of the prognosis 
may be nearly comprised in the following propositions: 

The more exactly the disease retains the form of the 
distinct kind, it is the safer; and the more completely 
the disease takes the form of the confluent kind, it is 
the more dangerous. 

It is only when the distinct kind shows a great num- 
ber of pustules on the face, or otherwise, by fever or 
putrescency, approaches to the circumstances of the 
confluent, that it is attended with any danger. 

In the confluent small-pox there is always danger; 
and this is always more considerable and certain, ac- 

VOL. I. % \ 



,370 PRACTICE OF PHYSIC. 

cording as the fever is more violent and permanent, 
and especially as the marks and symptoms of putres- 
cency are more evident. 

When the putrid disposition is very great, the dis- 
ease sometimes proves fatal before the eighth day, but, 
in most cases, it is on the eleventh that death happens, 
and sometimes it is put off till the fourteenth or seven- 
teenth day. 

Though the small-pox should not be immediately fa- 
tal, the more violent kinds are often followed by a mor- 
bid state of the body, of various kind and event. These 
consequences, as I judge, may be imputed sometimes 
to an acrid matter produced by the preceding disease, 
and deposited in different parts; and sometimes to an 
inflammatory diathesis produced, and determined to 
particular parts of the body. 

593. It is, I think, agreed among practitioners, that, 
in the different cases of small-pox, the difference chief- 
ly depends upon the appearance of distinct or conflu- 
ent; and from the above description of these kinds, it 
will appear, that they chiefly differ in the period of the 
eruption, in the number of pustules produced, in the 
form of the pustules, in the stale of the matter contain- 
ed in them, in the continuance of the fever, and, lastly, 
in the danger of the disease. 

594. Upon inquiring into the causes of these differ- 
ences, we might readily suspect, that they depended 
upon a difference of the contagion producing the dis- 
ease. This, however, is not probable; for there are in- 
numerable instances of the contagion, arising from a 
person labouring under the small-pox of the distinct 
kind, producing the confluent; and on the contrary. 
Since the practice of inoculation became frequent, we 
have known the same variolous matter produce in one 
person the distinct, and in another the eonfluent small- 



PRACTICE OF PHYSIC. 371 

pox. It is therefore highly probable, that the differ- 
ence of the small-pox does not depend upon any differ- 
ence of the contagion, but upon some difference in the 
state of the person to whom it is applied, or in the state 
of certain circumstances concurring with the applica- 
tion of the contagion. 

595. To find out wherein the difference in the state 
of the persons to whom the contagion of the small-pox 
is applied consists, I observe, that the difference be- 
tween the distinct and confluent small-pox consists es- 
pecially in the number of pustules produced, which, in 
the distinct, are generally few^ in the confluent, always 
many. If, therefore, we shall be able to discover what, 
in the state of different persons, can give occasion to 
more or fewer pustules, we shall probably be able to 
account for all the other differences of the distinct and 
confluent small-pox. 

596. It is evident, that the contagion of the small- 
pox is a ferment with respect to the human fluids, and 
assimilates a great part of them to its own nature; and 
it is probable, that the quantity thus assimilated is, in 
proportion to the bulk of their several bodies, nearly 
the same in different persons. This quantity passes 
again out of the body, partly by insensible perspiration, 
and partly by being deposited in pustules; but if the 
quantities generated be nearly equal, the quantities pass- 
ing out of the body by the two ways mentioned are 
very unequal in different persons; and, therefore, if we 
can explain the causes which determine more to pass 
by the one way than by the other, we may thereby dis- 
cover the causes which give occasion to more pustules 
in one person than in another. 

597. The causes which determine more of the vario- 
lous matter to pass by perspiration, or to form pustules, 
are probably certain circumstances of the skin, that do 



376 PRACTICE OF PHYSIC. 

termine more or less of the variolous matter to stick in 
it, or to pass freely through it. 

598. The circumstance of the skin, which seems to 
determine the variolous matter to stick in it, is a certain 
state of inflammation, depending much upon the heat of 
it. Thus, we have many instances of parts of the body, 
from being more heated, having a greater number of 
pustules than other parts. In the present practice of ino- 
culation, in which few pustules are produced, much 
seems to be owing to the care that is taken to keep the 
skin cool. Parts covered with plasters, especially with 
those of a stimulant kind, have more pustules than 
other parts. Further, certain circumstances, such as 
adult age, and full living, determining to a phlogistic 
diathesis, seem to produce a greater number of pus- 
tules; while the contrary circumstances have contrary 
effects. 

599. It is therefore probable, that an inflammatory 
state of the whole system, and more particularly of the 
skin, gives occasion to a greater number of pustules; 
and the causes of this may likewise produce most of 
the other circumstances of the confluent smalJ-pox; 
such as the period of eruption; the continuance of the 
fever; the effusion of a more putrescent matter, and less 
fit to be converted into pus; and, what arises from 
thence, the form and other circumstances of the pus- 
tules. 

600. Having thus attempted to account for the chief 
difference which occurs in the state of the smalJ-pox, 
we shall now try the truth of our doctrine, by its appli- 
cation to practice. 

60 1. In considering the practice, we view it first, in 
general, as suited to render the disease more gene- 
rally benign and safe, and this by the practice of inocu- 
lation. 



PRACTICE OF PHYSIC. 373 

602. It is not necessary here to describe the operation 
of inoculating; and what we name the practice of ino- 
culation, comprehends all the several measures which 
precede or follow that operation, and are supposed to 
produce its salutary effects. 

These measures are chiefly the following: 

1. The choosing for the subject of inoculation, per- 
sons otherwise free from disease, and not liable, from 
their age or other circumstances, to any incidental dis- 
ease. 

2. The choosing a person at the time of life most fa- 
vourable to a mild disease. 

3. The choosing for the practice a season the most 
conducive to the mildness of the disease. 

4. The preparing the person to be inoculated, by 
abstinence from animal food, for some time before ino- 
culation. 

5. The preparing the person by courses of mercurial 
and antimonial medicines. 

6. The taking care, at the time of inoculation, to avoid 
cold, intemperance, fear, or other circumstances which 
might aggravate the future disease. 

7. After these preparations and precautions, the choos- 
ing a fit matter to be employed in inoculation, by taking 
it from a person of a sound constitution, and free from 
any disease or suspicion of it; by taking it from a per- 
son who has had the small-pox of the most benign 
kind; and, lastly, by taking the matter from such per- 
sons, as soon as it has appeared in the pustules either 
in the part inoculated, or on other parts of the body. 

8. The introducing, by inoculation, but a small por- 
tion of the contagious matter. 

9. x\fter inoculation, the continuing the vegetable 
diet, as well as the employment of mercurial and anti- 



374 PRACTICE OF PHYSIC. 

monial medicines, and, at the same time, frequently em- 
ploying purgatives. 

10. Both before and after inoculation, taking care to 
avoid external heat, either from the sun, artificial fires, 
warm chambers, much clothing, or being much in bed; 
and, on the contrary, exposing the person to a free and 
cool air. 

11. Upon the appearance of the eruptive fever, the 
rendering that moderate by the employment of purga- 
tives, by the use of cooling and antiseptic acids, and 
especially by exposing the person frequently to a cool, 
and even a cold air, at the same time giving freely of 
cold drink. 

12. After the eruption, the continuing the applica- 
tion of cold air, and the use of purgatives, during 
the course of the disease, until the pustules are fully 
ripened. 

603. These are the measures proposed and practised 
in the latest and most improved state of inoculation; and 
the advantages obtained by the whole of the practice, 
or at least by most of the measures above mentioned, 
are now ascertained, by a long experience, to amount to 
this. That in ninety-nine cases of the hundred, inocula- 
tion gives a distinct small-pox only, and that also very 
generally of the mildest form ; but it will still be useful, 
for the proper conduct of inoculation, to consider the 
importance and utility of the several measures above 
mentioned, that we may thereby more exactly determine 
upon what the advantages of inoculation more certainly 
depend. 

604. As the common infection may often seize per- 
sons labouring under another disease, which may ren- 
der the small-pox more violent, it is obvious that ino- 
culation must have a great advantage, by avoiding such 



PRACTICE OF PHYSIC. 375 

concurrence. But as the avoiding such concurrence 
may often, in the mean while, leave persons exposed to 
the common infection, it merits inquiry, whether every 
diseased state should restrain from the practice of ino- 
culation, or what are the particular diseases that should 
do so. This is not yet sufficiently ascertained by obser- 
vation; and we have frequently remarked, that the small- 
pox have often occurred with a diseased state of the 
body, without being thereby rendered more violent. In 
particular, we have observed, that a scrofulous habit, or 
even the presence of scrofula, did not render the small- 
pox more violent; and we have observed also, that seve- 
ral diseases of the skin are equally innocent. I am of 
opinion, that they are the diseases of the febrile kind, or 
ailments ready to induce or aggravate a febrile state, 
that especially give the concurrence which is most dan- 
gerous with the small-pox. I dare not attempt any ge- 
neral rules; but I am disposed to maintain, that, though 
a person be in a diseased state, if that state be of un- 
certain nature and effect, and, at the same time, the 
small-pox be exceedingly rife, so as to render it ex- 
tremely difficult to guard against the common infection, 
it will always be safer to give the small-pox by inocula- 
tion, than to leave the person to take them by the com- 
mon infection. 

605. Though inoculation has been practised with 
safety upon persons of all ages; yet, from what has ac- 
tually occurred in the cases of common infection, and 
from several other considerations, there is reason to 
conclude, that adults are more liable to a violent disease 
than persons of younger years. At the same time, it is 
observed, that children, in the time of their first denti- 
tion, are liable, from this irritation, to have the small- 
pox rendered more violent; and that infants, before the 
time of dentition, upon receiving the contagion of the 



376 PRACTICE OF PHYSIC. 

small-pox, are liable to be affected with epileptic fits, 
which frequently prove fatal. It is, therefore, upon the 
whole, evident, that though circumstances may admit, 
and even render inoculation at any age proper, yet, for 
the most part, it will be still more advisable to choose 
persons at an age, after the first dentition is over, and 
before the time of puberty. 

606. Though inoculation has been practised with 
safety at every season of the year, yet, as it is certain 
that the cold of winter may increase the inflammatory, 
and the heats of summer increase the putrescent state 
of the small-pox, it is highly probable, that inoculation 
may have some advantage, from avoiding the extremes 
either of heat or cold. 

607. Although the original temperament and constitu- 
tions of men are not to be readily changed, it is suffi- 
ciently certain, that the conditions of the human body 
may, by various causes, in many respects be occasion- 
ally very much changed, and therefore as the use of 
animal food may increase both the inflammatory and 
putrescent state of the human body, so it must render 
persons, on receiving the contagion of the small-pox, 
less secure against a violent disease; and therefore ino- 
culation may derive some advantage from abstinence 
from animal food for some time before the inoculation 
is performed: but I am of opinion, that a longer time 
than that usually prescribed may be often necessary; 
and I am persuaded, that the Scottish mothers who 
avoid giving their children animal food till they are past 
the small-pox, render this disease in them of a milder 
kind. 

608. 1 cannot deny that mercurial and antimonial me- 
dicines may have some effect in determining to a more 
free perspiration, and therefore may be of some use in 
preparing a person for the small-pox; but there are 



PRACTICE OF PHYSIC SI' 

many observations which render me doubtful as to their 
effect. The quantity of both these medicines, par- 
ticularly of the antimony commonly employed, is too 
inconsiderable to produce any effect. It is true that the 
mercurials have often been employed more freely; but 
even their salutary effects have not been evident, and 
their mischievous effects have sometimes appeared. I 
doubt, therefore, 'upon the whole, if inoculation derives 
any advantage from these pretended preparatory courses 
of medicines. 

609. As it has been often observed, in the case of al- 
most all contagions, that cold, intemperance, fear, and 
some other circumstances, concurring with the applica- 
tion of the contagion, have greatly aggravated the future 
disease, so it must be the same in the case of the small- 
pox; and it is undoubted, that inoculation must derive 
a great, and perhaps its principal advantage, from avoid- 
ing the concurrences above mentioned. 

010. It has been commonly supposed, that inocula- 
tion has derived some advantage from the choice of the 
matter employed in it; but, from what has been observed 
in 594, it must appear very doubtful if any choice be 
necessary, or can be of any benefit in determining the 
state of the disease. 

611. It has been supposed by some, that inoculation 
has an advantage, by introducing a small portion only 
of the contagious matter: but this rests upon an uncer- 
tain foundation. It is not known what quantity is intro- 
duced by the common infection, and it may be a small 
quantity only. Although it were larger than that thrown 
in by inoculation, it is not ascertained that the circum- 
stance of quantity would have any effect. A certain 
quantity of ferment may be necessary to excite fermenta- 
tion in a given mass: but that quantity given, the fer- 
mentation and assimilation are extended to the whole 

vol. i. 3 b 



378 PRACTICE OF PHYSIC. 

mass; and wo do not find that a greater quanf'ty than 
is just necessary, either increases the activity of the fer- 
mentation, or more certainly secures the assimilation ol 
the whole. In the case of the small-pox, a considera- 
ble difference in the quantity of contagious matter in- 
troduced, has not discovered any effect in modifying the 
disease. 

612. Purging has the effect of diminishing the activity 
of the sanguiferous system, and of obviating its inflam- 
matory state. It is, therefore, probable, that the frequent 
use of cooling purgatives is a practice attending inocu- 
lation which may be of considerable advantage; and, 
probably, it is also useful by diminishing ihe determina- 
tion to the skin. It appears to me, that mercurials and 
antimonials, as they are commonly managed, are useful 
only as they make a part of the purging course. 

613. It is probable, that the state of the small-pox de- 
pends very much upon the state of the eruptive fever, 
and particularly upon moderating the inflammatory state 
of the skin; and, therefore, it is probable, that the mea- 
sures taken for moderating the eruptive fever and in- 
flammatory state of the skin, afford the greatest im- 
provement which has been made in the practice of ino- 
culation. The tendency of purging, and the use of 
acids for this purpose is sufficiently obvious; and upon 
the same ground we should suppose, that blood-letting 
might be useful; but probably this has been omitted, for. 
the same reason that might perhaps have led to the 
omission of other remedies also; which is, that we have 
found a more powerful and effectual one in the applica- 
tion of cold air, and the use of cold drink. Whatever 
doubts or difficulties our theory might present to us on 
this subject, they may he entirely neglected, as the prac- 
tice of Indostan had long ago, and the practice of this 
country has lately, by a large and repeated experience, 



PRACTICE OF PHYSIC. 379 

ascertained the safety and efficacy of this remedy: and 
as it may and can be more certainly employed with the 
practice of inoculation, than it can be in cases of com- 
mon infection, it must give a singular advantage to the 
former. 

614. After the eruption, when a few pimples only 
have appeared on the face, the continuing the applica- 
tion of cold air, and the employment of purgatives, 
has indeed been the practice of many inoculators: but I 
think these practices cannot be said to give any peculiar 
advantages to inoculation; for when the state of the 
eruption is determined, when the number of pustules 
is very small, and the fever has entirely ceased, I hold 
the safety of the disease to be absolutely ascertained, 
and the further use of remedies entirely superfluous. In 
such cases, I judge the use of purgatives to be not only 
unnecessary, but that they may be often hurtful. 

615. 1 have thus considered the several circumstances 
and practices accompanying inoculation, and have en- 
deavoured to ascertain the utility and importance of 
each. Upon the whole, I hope I have sufficiently as- 
certained the general utility and great advantage of this 
practice, especially consisting in this, that if certain pre- 
cautions, preparations, and remedies, are of importance, 
all of them can be employed with more certainty in the 
practice of inoculation, than in the case of common in- 
fection. 

It remains now that I should offer some remarks on 
the conduct of the small-pox. as received by infection, 
or even when, after inoculation, the symptoms shall 
prove violent. The latter sometimes happens, although 
every precaution and remedy have been employed. The 
cause of this is not well known; but it appears to me to 
be commonly owing to a disposition of the fluids to putres- 
cency. But, however this may be, it will appear, that, 



380 PRACTICE OF PHYSK 

not only in the case of common infection, but even in 
that of inoculation, there may be occasion for studying 
the conduct of this disease, in all its possible varying 
circumstances. 

616. When, from the prevailing of small-pox as an 
epidemic, and more especially when it is known that a 
person, not formerly affected with the disease, has been 
exposed to the infection, if such person should be seized 
with the symptoms of fever, there can be little doubt of 
its being an attack of the small-pox; and, therefore, he is 
to be treated in every respect as if the disease had been 
received by inoculation. He is to be freely exposed to 
a cool air, to be purged, and to have cooling acids given 
liberally. 

617. If these measures moderate the fever, nothing 
more is necessary: but if the nature of the fever attack- 
ing a person be uncertain; or if, with suspicions of the 
small-pox, the symptoms of the fever be violent: or even 
if, knowing the disease to be the small-pox, the measures 
mentioned (596.) shall not moderate the fever suffici- 
ciently; it will be proper to let some blood: and this 
will be more especially proper, if the person be an adult, 
of a plethoric habit, and accustomed to full living. 

618. In the same circumstances, we judge it will be 
always proper to give a vomit, as useful in the com- 
mencement of all fevers, and more especially in this, 
where a determination to the stomach appears from 
pain aud spontaneous vomiting. 

619. It frequently happens, especially in infants, that 
during the eruptive fever of the small-pox, convulsions 
occur. Of these, if only one or two fits appear on the 
evening preceding the eruption, they give a favourable 
prognostic of a mild disease, and require no remedy; 
but if they occur more early, and be violent and fre- 
quently repeated, they are very dangerous, and require 



PRACTICE OF PHYSIC. 381 

a speedy remedy. For this purpose, bleeding is hardly 
ever of service; blistering always comes too late; and 
the only remedy I have found effectual, is an opiate 
given in a large dose. 

620. These are the remedies necessary during the 
eruptive fever; and if, upon the eruption, the pimples 
upon the face be very few and distinct, the disease is no 
further of any danger, requires no remedies, and the 
purgatives, which, as has been said before, are by some 
practitioners continued, prove often hurtful. 

But when, upon the eruption, the pimples on the face 
are very numerous; when they are not distinct; and es- 
pecially when, upon the fifth day, the fever does not suf- 
fer a considerable remission, the disease will still re- 
quire a great deal of attention. 

6,21. If, after the eruption, the fever shall continue, 
the avoiding heat, and continuing to expose the body to 
a cool air, will still be proper. If the fever be con- 
siderable, with a full and hard pulse, in an adult person, 
a bleeding will be necessary; and, more certainly, a 
cooling purgative. It is, however, seldom that a repe- 
tition of the bleeding will be proper, as a loss of strength 
does usually come on very soon; but the repetition of a 
purgative, or the frequent use of laxative glysters, is 
commonly useful. 

622. When loss of strength, with other marks of a 
putrescent tendency of the fluids, appears, it will be ne- 
cessary to exhibit the Peruvian bark in substance, and 
in large quantity. In the same case, the free use of 
acids, and of nitre, is useful; and it is commonly proper 
also to give wine very freely. 

623. From the fifth day of the disease, onward through 
the whole course of it, it is proper to give an opiate 
once or twice a-day; taking care, at the same time, to 
obviate costiveness, by purgatives or laxative glysters. 



382 PRACTICE OF PHYSIC. 

624. In a violent disease, from the eighth to the ele- 
venth day, it is proper to lay on blisters successively on 
diffident parts of the body; and that without regard to 
the parts being covered with pustules. 

625. If, in this disease, the tumour of the fauces be 
considerable; the deglutition difficult; the saliva and mu- 
cus viscid, and with difficulty thrown out; it will be 
proper to apply blisters to the external fauces, and to 
employ diligently detergent gargles. 

626. During the whole course of the disease, when 
any considerable fever is present, the frequent exhibi- 
tion of antimonial medicines, in nauseating doses, has 
been found useful; and these, for the most part, suffi- 
ciently answer the purpose of purgatives. 

627. The remedies mentioned from 621. to 625. are 
those frequently necessary, from the fifth day till the 
suppuration is finished. But as, after that period, the 
fever is sometimes continued and increased; or, as some- 
times, when after there has been little or no fever be- 
fore, a fever now arises, and continues with considera- 
ble danger; this is what is called the Secondary Fever, 
and requires particular treatment. 

628. When the secondary fever follows the distinct 
small-pox, and the pulse is full and hard, the case is to 
be treated as an inflammatory affection, by bleeding and 
purging, but if the secondary fever follow the confluent 
small-pox, and be a continuance or exacerbation of the 
fever which had subsisted before, it is to be considered 
as of the putrid kind; and in that case, bleeding is im- 
proper. Some purging may be necessary; but the re- 
medies to be chiefly depended on, are the Peruvian 
bark and acids. 

When the secondary fever first appears, whether it is 
after a distinct or confluent small-pox, it will be useful 



PRACTICE OF PHYSIC. 383 

to exhibit an antimonial emetic in nauseating doses, but 
in such a manner as to produce some vomiting. 

629; For avoiding the pits which frequently follow 
the small-pox, many different measures have been pro- 
posed; but none of them appear to be sufficiently certain. 



CHAPTER II. 
OF THE CHICKEN-POX.* 

630. THIS disease seems to depend upon a specific 
contagion, and to affect persons but once in their lives, 
It is hardly ever attended with any danger; but as it 
seems frequently to have given occasion to the supposi- 
tion of a person's having the small-pox twice, it is proper 
to study this disease, and to distinguish it from the ge- 
nuine small-pox. 

631. This may be generally done by attending to the 
following circumstances. , 

The eruption of the chicken-pox comes on with very 
little fever preceding it, or with fever of no determined 
duration. 

* Chicken-pox, being a febrile disease of excessive action, requires, at 
all times, as far as medical aid may become necessary in it, the antiphlogistic 
plan of treatment. Of the extent to which this plan should be carried, the 
practitioner will easily judge from the character of the attack. 

Sometimes, from improper exposure, or other causes, the eruption, before 
it is completed, suddenly disappears. In such cases, considerable nausea, 
or vomiting, and prostration of strength almost immediately ensue 

Under such circumstances, an emetic, by changing the action of the sto- 
mach, and determining again to the surface, is highly useful. 

This, followed by the use of warm sage, or balm tea, or some other vege- 
table infusion, gently stimulating, restores the eruption and relieves the 
complaint. 

All eruptive diseases, we have said, originate in the stomach. This truth 
very clearly appears, from the serious manner in which that organ suffers, 
when, from any cause, the eruption recedes from the surface of the bodv. 



384 PRACTICE OF PHYSIC. 

The pimples of the chicken-pox, more quickly than 
those of the small-pox, are formed into little vesicles or 
pustules. 

The matter in these pustules remains fluid, and never 
acquires the colour or consistence of the pus which ap- 
pears in the pustules of the small-pox. 

The pustules of the chicken-pox are always, in three 
or four days from their first appearance, formed into 
crusts. 

See Dr. Heberden in Med. Transact. Vol. I. art. xvii. 



CIIAFTEll III. 
OF THE MEASLES. 



632. XHIS disease also depends upon a specific conta- 
gion, and affects persons but once in their lives.* 

* However visionary it might appear in us to doubt; or heterodox to deny, 
the contagious nature of measles, we acknowledge ourselves unable, defini- 
tively, to prove it. 

Measles cannot be propagated by inoculation; the oidy conclusive test of 
contagion with which we are acquainted. Every other may prove delusive. 

This complaint, when it does prevail, assumes, we believe, always, the cha- 
racter of an epidemic ,• which is only another name for an atmospheric disease. 
There exists not a doubt, therefore, that it often, at least, makes its appear- 
ance in places, into which it has not been introduced by means of contagion. 
We have repeatedly been witness to such an occurrence. 

If, from a place where measles prevails, one or more cases be removed to 
a distant part, where it did not before exist, it does not spread from the sick 
as from a centre of contagion. It usually, if not uniformly, disappears, with 
the death or recovery of the persons affected. Nor is it until it arrives at 
this place, in the form of an epidemic, that it actually spreads among the in- 
habitants. Of this we speak confidently, for we have witnessed the event. 
If it be contagious, therefore, the laws of its communication are materially 
different from those of small-pox— a disease, which, in all places, and under 
all circumstances, spreads among those who have not been affected by it ; 
provided they come within the sphere of its action. 

The strongest marks of a specifically contagious disease which measles 



PRACTICE OF PHYSIC. 385 

ti33. It occurs most frequently in children; but no 
age is exempted from it, if the persons have not been 
subjected to it before. 

6.34. It commonly appears as an epidemic, first in 
the month of January, and ceases soon after the sum- 
mer solstice; but various accidents, introducing the con- 
tagion, may produce the disease at other times of the 

year. 

635. The disease always begins with a cold stage, 
which is soon followed by a hot, with the ordinary 
symptoms of thirst, heat, anorexia, anxiety, sickness, 
and vomiting; and these are more or less considerable 
in different cases. Sometimes, from the beginning, the 
fever is sharp and violent; often, for the first two days, 
it is obscure and inconsiderable, but always becomes 
violent before the eruption, which usually happens 
upon the fourth day* 

636. This eruptive fever, from its commencement, is 
always attended with hoarseness, with a frequent hoarse 
dry cough, and frequently with some difficulty of breath- 
ing. At the same time, the eye-lids are somewhat 
swelled, the eyes are a little inflamed, and pour out 
tears; and, together with these symptoms, there is a 
coryza, and frequent sneezing. For the most part, a 
constant drowsiness attends the beginning of this dis- 
ease. 

637. The eruption, as we have said, commonly ap- 
pears upon the fourth day, first on the face, and succes- 

possesses, are, its peculiar appearance, and that it affects persons but once 
in the course of their lives Remove these characteristics, and the evi- 
dences of its contagion are scarcely stronger than those that are exhibited 
by intermitting fever. 

» We have known the fever of measles to have continued more than a week, 
before the appearance of the eruption. A case of this kind fell, very ir 
cently, under our notice. 

vol. I. 3 r 



386 PRACTICE OF PHYSIC. 

sively on the lower parts of the body. It discovers 
itself first in small red points; but, soon after, a num- 
ber of these appear in clusters, which do uot arise into 
visible pimples, but, by the touch are found to be a little 
prominent. This is the case on the face; but, on other 
parts of the body, the prominence, or roughness, is 
hardly to be perceived. On the face the eruption re- 
tains its redness, or has that increased for two days: 
but, on the third, the vivid redness is changed to a 
brownish red; and, in a day or two more, the eruption 
entirely disappears, while a mealy desquamation takes 
place. During the whole time of the eruption, the face 
is somewhat turgid, but seldom considerably swelled. 

638. Sometimes, after the eruption has appeared, the 
fever ceases entirely: but this is seldom the case; and 
more commonly the fever continues, or is increased 
after the eruption, and does not cease till after the des- 
quamation. Even then the fever does not always cease, 
but continues with various duration and effect. 

639. Though the fever happen to cease upon the 
eruption's taking place, it is common for the cough to 
continue till after the desquamation, and sometimes 
much longer. 

In all cases, while the fever continues, the cough also 
continues, generally with an increase of the difficulty of 
breathing; and both these symptoms sometimes arise to 
a degree that denotes a pneumonic affection. This 
may arise at any period of the disease; but very often it 
does not come on till after the desquamation of the 
eruption. 

After the same period, also, a diarrhoea frequently 
comes on, and continues for some time. 

640. It is common for the measles, even when they 
have not been of a violent kind, to be succeeded by 



PRACTICE OF PHYSIC. 387 

inflammatory affections, particularly ophthalmia and 
phthisis.* 

641. If the blood be drawn from a vein during the 
measles, with the circumstances necessary to favour the 
separation of the gluten, this always appears separated, 
and lying on the surface of the crassamentum, as in in- 
flammatory diseases. 

642. For the most part, the measles, even when vio- 
lent, are without any putrid tendency, but in some cases, 
such a tendency appears, both in the course of the dis- 
ease, and especially after the ordinary course of it is 
finished. See Dr. Watson, in London Med. Observa- 
tions, Vol. IV. art. xi. 

643. From what is delivered, from 636. to 641, it 
will appear, that the measles are distinguished by a ca- 
tarrhal affection, and by an inflammatory diathesis to a 
considerable degree, and therefore the danger attending 
them arises chiefly from the coming on of a pneumonic 
inflammation. 

644. From this consideration it will be obvious, that 
the remedies especially necessary, are those which may 
obviate and diminish the inflammatory diathesis; and 
therefore, in a particular manner, blood-letting. This 
remedy may be employed at any time in the course of 
the disease, or after its ordinary course is finished. It 
is to be employed more or less according to the urgency 
of the symptoms of fever, cough, and dyspnoea; and 
generally may be employed very freely. But as the 
symptoms of pneumonic inflammation seldom come on 
during the eruptive fever; and, as this fever is some- 
times violent immediately before the eruption, though a 
sufficiently mild disease be to follow; so bleeding is sel- 

* These unfavourable terminations of measles very rarely occur, except 
as the result of neglect or unskilful treatment. Practise venesection to a 
sufficient extent, and avoid cold and improper exposure, and you effectuallv 
prevent them, 



3S8 PRACTICE OF PHYSIC. 

dom very necessary during the eruptive fever, and m 

often be reserved for the periods of greater danger 

which perhaps are to ensue.* 
645. In all cases of measles, where there are no marks 

of putrescency, and where there is no reason, from the 
known nature of the epidemic, to apprehend putres- 
cency, bleeding is the remedy to be depended upon; but 
assistance may also be obtained from cooling purga- 
tives; and particularly from blistering on the sides, or 
between the shoulders.f 

646. The dry cough may be alleviated by the large 
use of demulcent pectorals, mucilaginous, oily, or sweet. 
It may, however, be observed, with respect to these de- 
mulcents, that they are not so powerful in involving and 
correcting the acrimony of the mass of blood as has 
been imagined; and that their chief operation is by be- 
smearing the fauces, and thereby defending them from 
the irritation of acrids, either arising from the lungs, or 
distilling from the head.J 

647. For moderating and quieting the cough in this 
disease, opiates certainly prove the most effectual means, 
whenever they can be safely employed. In the measles, 
in which an inflammatory state prevails in a considerable 
degree, opiates may be supposed to be inadmissible; 
and, in those cases in which a high degree of pyrexia 

• We are inclined to believe, that the judicious employment of the lancet., 
as well as of emetics, facilitates very much the appearance of the eruption. 
Confident we are, that venesection, during the eruptive fever, often affords 
immediate relief, without being productive of subsequent injury. It is, there- 
fore, a valuable remedy. 

| When symptoms of pneumonic inflammation exist, blistering on some 
part of the thorax, the part to be directed by the seat of the pain, is as es- 
sential in measles as it is in peripneumony. 

$ Flax-seed tea, bran tea, barley water, and gum arabic dissolved in wa- 
ter, make excellent drinks in measles ; but, with the oily preparations we 
are not pleased, because we consider them too stimulating. They excite too 
much action in the stomach, and, hence, in other parts, by sympathy. The 
Mood, we believe, to be as free from acrimony in measles, as it is in health 



PRACTICE OF PHYSIC. 389 

and dyspnoea show either the presence, or at least the 
danger, of pneumonic inflammation, I think that opiates 
might be very hurtful. In cases, however, in which the 
dyspnoea is not considerable, and where bleeding, to 
obviate or abate the inflammatory state, has been duly 
employed, and where the cough and watchfulness are 
the urgent symptoms, I think that opiates may be safely 
exhibited, and with great advantage. I think, further, 
that in all the exanthemata, there is an acrimony dif- 
fused over the system, which gives a considerable irrita- 
tion; and, for obviating the etfects of this, opiates are 
useful, and always proper, when no particular contra- 
indication prevails.* 

648. When the desquamation of the measles is finish- 
ed, though there should then be no disorder remaining, 
physicians have thought it necessary to purge the pa- 
tient several times, with a view to draw off' the dregs 
of this disease, that is, a portion of the morbific mat- 
ter which is supposed to remain long in the body. I can- 
not reject this supposition; but, at the same time, cannot 
believe, that the remains of the morbific matter, dif- 
fused over the whole mass of blood, can be entirely 
drawn off by purging; and, it appears to me, that, to 
avoid the consequences of the measles, it is not the 
drawing off the morbific matter which we need to study, 

* When, by means of blood-letting, and other remedies, the febrile symp- 
toms are so far subdued, that the complaint is little else than a disease of 
local irritation, opiates should be administered precisely as in other diseases 
of a similar character. To relieve the cough, which always accompanies 
measles, and the diarrhaa, which often makes its appearance towards the 
close of the complaint, opiates, in some form, constitute the only effectual 
remedy. The following formula, we have found pleasant and useful : viz. 
R Mucilag. Gum, Arab. ) 

Aq. Cinnamom. seu Lavend. simp.$ ^ * n ' 

Aq. Font. |iy. 

Tinct. Thebaic. 3i. 

Sacch. alb. q. s. m. ft. Julep. 
Of this, a full table-spoonful may be taken at a dose, by an adult, and re- 
peated as often as circumstances require it. 



390 PRACTICE OF PHYSIC. 

so much as the obviating and removing the inflamma- 
tory state of the system which had been induced by the 
disease. With this last view, indeed, purging may still 
be a proper remedy ; but bleeding, in proportion to the 
symptoms of inflammatory disposition, is yet more so.* 

649. From our late experience of the benefit of cold 
air in the eruptive fever of the small-pox, some physi- 
cians have been of opinion that the practice might be 
transferred to the measles: but we have not yet had 
trials sufficient to ascertain this. 

There is no doubt that external heat may be very 
hurtful in the measles, as in most other inflammatory 
diseases; and therefore the body ought to be kept in a 
moderate temperature during the whole course of the 
measles; but how far, at any period of the disease, cold 
air may be applied with safety, we are yet uncertain. 
Analogy, though so often the resource of physicians, is, 
in general, fallacious; and further, though the analogy 
with the small-pox might lead to the application of cold 
air during the eruptive fever of the measles, the analogy 
with catarrh seems to be against the practice. After 
the eruption had appeared upon the skin, we have had 
many instances of cold air making it disappear, and 
thereby producing much disorder in the system; and 
have also had frequent examples of such disorder being 
removed by restoring the heat of the body, and thereby 
again bringing forth the eruption.f 

* If, in this article, the mind of Dr. Cullen be correctly represented, it 
retained a strong bias towards the errors of the humoral pathology 

In case inflammation, on the decline of measles, threaten to fix itself 
in an ophthalmic, a catarrhal, or a pneumonic form, the liberal use of the lan- 
cet, of blisters, and other antiphlogistic remedies, becomes essential. Under 
these circumstances, no truce should be given to the disease ; but it ought 
to be resolutely, and' perse veringly assailed, until it be completely eradicat- 
ed. This measure we hold to be essential ; for, there is no complaint, which, 
if neglected towards its close, leaves behind it more troublesome affections 
than measles. 

f The temperature of the chamber, in the treatment of measles, should 



PRACTICE OF PHYSIC. 391 

CHAPTER IV. 

OF THE SCARLET FEVER.* 

650. IT may be doubted if the scarlet fever be a dis- 
ease specifically different from the Cynanche Maligna 
above described. The latter is almost always attended 
with a scarlet eruption; and, in all the instances I have 
seen of what may be called the scarlet fever, the dis- 
ease, in almost every person affected, has been attend- 
ed with an ulcerous sore throat. 

be precisely the same as in that of peripneumony— moderate— not in either 
extreme. Of the two, a temperature a little too high, is less apt to prove 
injurious, than one too low. Here, as in the treatment of most other febrile 
affections, the punctum jucundum of temperature should be carefully preserv- 
ed. Whatever degree of heat or cold produces, on the system, an unpleasant 
impression, is an irritant, will increase fever, and ought, therefore, to be 
avoided. 

* Notwithstanding all Dr. Cullen's reasoning in this chapter, we are 
strongly inclined to believe, that Scarlatina Anginosa, and Cynanche Ma- 
ligna, are but different forms or degrees of the same disease. They stand 
related to each other, precisely as the distinct and the confluent small-pox - 
wh.ch were also, at a former, and not a very remote period, regarded as dis- 
eases specifically different. 

Indeed, we think the identity of Scarlatina Anginosa, and Cynanche Ma- 
l.gna, very fairly to be inferred, even from the statement of our author re 
spectmg them : for, he admits, that, when epidemic, these forms of disease 
always accompany each other; but in inverse ratios: and, it is well known 
that two ep.demics never prevail at the same time. They must, therefore' 

11 J?? , Wed ° Ubt ' h ° WeVer ' their -« ^ing propagated by co a 
ff on. We feel persuaded they never are , but, that they are exclusively at- 
rnosphenc d.sease, They both have their primary affection in the stl 

The poison of scarlatina anginosa, whatever may be its nature, operates 

SET Vr™ ^ * reat,y dissimiI - ^ the operation Arsenic 

thro, Vn T P rod "«s sickness at stomach, an inflammation of the 

does h 1 r C % an T UPti ° n °" thC Skin ' aBd Sn anaS — filing. So 

does th matter of scarlatma anginosa. But arsenic, in producing its effects 

cts on the stomach alone. So, we are persuaded, does the poifon of scar 



392 PRACTICE OF PHYSIC: 

651 . This view of the matter may create some doubt; 
but I am still of opinion, that there is a scarlet fever 
which is a disease specifically different from the Cy- 
nanche Maligna. 

Dr. Sydenham has described a scarlet fever, which 
he had seen prevailing as an epidemic, with all the cir- 
cumstances of the fever and eruption, without its being 
accompanied with any affection of the throat; at least 
he does not take notice of any such affection, which 
such an accurate observer could not fail to have done, 
if any such symptom, as we have commonly seen mak- 
ing a principal part of the disease, had attended those 
cases which he had observed. Several other writers 
have described the scarlet fever in the same manner, 
and 1 know physicians who have seen the disease in 
that form; so that there can be no doubt of there being 
a scarlet fever not necessarily connected with an ulcer- 
ous sore throat, and therefore a disease different from 
the Cynanche Maligna. 

652. But, further, although in all the instances of 
scarlet fever which I have seen, (and in the course of 
forty years I have seen it six or seven times prevailing 
as an epidemic in Scotland) the disease, in almost all 
the persons affected, was attended with an ulcerous sore 
throat, or was what Sauvages names the Scarlatina 
Anginosa; and although, in some instances the ulcers 
of the throat were of a putrid and gangrenous kind, and 
at the same time the disease in all its symptoms resem- 
bled very exactly the Cynanche Maligna; yet I am still 
persuaded, that not only the Scarlatina of Sydenham, 
but that even the Scarlatina Anginosa of Sauvages, is 
a different disease from the Cynanche Maligna; and I 
have formed this opinion from the following considera- 
tions: 

653. 1st. There is a scarlet fever entirely free from 



PRACTICE OF PHYSIC. 39S 

any affection of the throat which sometimes prevails as 
an epidemic; and therefore there is a specific contagion 
producing a scarlet eruption without any determination 
to the throat. 

2dly, The Scarlatina, which, from its matter being 
generally determined to the throat, may be properly 
termed Anginosa, has, in many cases of the same epi- 
demic, been without any affection of the throat; and 
therefore the contagion may be supposed to be more 
especially determined to produce the eruption only. 

3dly, Though in all the epidemics that I could allege 
to be those of tiie Scarlatina Anginosa, there have been 
some cases, which, in the nature of the ulcers, and in 
other circumstances, exactly resembled the cases of the 
Cynanche Maligna; yet I have as constantly remarked, 
that these cases have not been above one or two in a 
hundred, while the rest have all of them been with ul- 
cers of a benign kind, and with circumstances hereaf- 
ter to be described, somewhat different from those of 
the Cynanche Maligna. 

4thly, On the other hand, as I have two or three times 
seen the Cynanche Maligna epidemically prevailing; so, 
among the persons affected, I have seen instances of 
cases as mild as those of the Scarlatina Anginosa usu- 
ally are: but here the proportion was reversed; these 
mild cases were not one fifth of the whole, while the 
rest were of the putrid and malignant kind. 

Lastly, It applies to the same purpose to observe, 
that, of the Cynanche Maligna, most of the instances 
terminate fatally; while, on the other hand, that is the 
event of very few of the cases of the Scarlatina An- 
ginosa. 

654. From these considerations, though it may ap- 
pear that there is some affinity between the Cynanche 
Maligna and Scarlatina Anginosa, it will still remain 

vol, i. 3d 



394 PRACTICE OF PHYSIC . 

probable that the two diseases are specifically different, 
I have been at some pains to establish this opinion: for, 
from all my experience, I find, that those two diseases 
require a different treatment; and I therefore now pro- 
ceed to mention more particularly the circumstances oi 
the Scarlatina Anginosa. 

655. This disease- commonly appears about the be- 
ginning of winter, and continues throughout that season. 
It comes on with some cold shivering, and other symp- 
toms of the fever which usually introduces the other 
exanthemata. But here there is no cough, nor the 
other catarrhal symptoms which attend the measles; 
nor is there that anxiety and vomiting which commonly 
introduce the confluent small-pox, and which more 
certainly introduce the Cynanche Maligna. 

Early in the disease some uneasiness is felt in the 
throat; and frequently the deglutition is difficult, gene- 
rally more so than in the Cynanche Maligna. Upon 
looking into the fauces, a redness and swelling appear, 
in colour and bulk approaching to the state of these 
symptoms in the Cynanche Tonsillaris; but in the Scar- 
latina there is always more or less of sloughs, which 
seldom appear in the Cynanche Tonsillaris; and the 
sloughs are commonly whiter than those in the Cynan- 
che Maligna. 

While these appearances are discovered in the fau- 
ces, upon the third or fourth day, a scarlet eruption ap- 
pears on the skin, in the same form as described in 
311. This eruption is commonly more considerable 
and universal than in the Cynanche; but it seldom pro- 
duces a remission of the fever. The eruption for the 
most part remains till the third or fourth day after its 
first appearance; but then goes off, ending in a meally 
desquamation. At this time the fever usually subsides 



PRACTICE OF PHYSIC. 395 

and generally, at the same time, some degree of sweat 
comes on. 

The sloughs on the fauces,, which appeared early in 
the disease, continue for some days; but then falling off, 
discover the swelling abated, and an ulcer formed on 
one or both tonsils showing a laudable pus; and soon 
after the fever has subsided, these ulcers heal up en- 
tirely. For the most part this disease has much less 
of coryza attending it than the Cynanche Maligna; and, 
when there is a coryza attending the Scarlatina, the 
matter discharged is less acrid, and has not the fetid 
smell which it has in the other disease. 

In the Scarlatina, when the eruption has entirely 
disappeared, it frequently happens, that in a few days 
after, the whole body is affected with an anasarcous 
swelling; which, however, in a few days more, gradu- 
ally subsides. 

We have thus described the most common circum- 
stances of the Scarlatina Anginosa; and have only to 
add, that during the time of its being epidemic, and es- 
pecially upon its first setting in, there are always a few 
cases in which the circumstances of the disease ap- 
proach very nearly to those of the Cynanche Maligna: 
and it is only in these instances that the disease is at- 
tended with any danger. 

656. With respect to the cure of this disease, when 
the symptoms of it are nearly the same with those of 
the Cynanche Maligna, it requires exactly the same 
treatment as directed in 317. 

657. When the scarlet fever appears without any af- 
fection of the throat, the treatment of it is very simple, 
and is delivered by Dr. Sydenham. An antiphlogistic 
regimen is commonly all that is requisite; avoiding, on 
one hand, the application of cold air; and, on the other, 
any increase of external heat. 



396 PRACTICE or P1IYSK 

658. In the ordinary state of the Scarlatina Angihosa, 
the same treatment is. in most cases, sufficient; but as 
here the fever is commonly more considerable, and 
there is likewise an affection of the throat, some reme- 
dies may be often necessary. 

659. When there is a pretty high degree of fever, 
with a full pulse, and a considerable swelling of the 
tonsils, bleeding is very proper, especially in adults; and 
it has been frequently practised with advantage: but as, 
even in the Cynanche Tonsillaris, much bleeding is 
seldom necessary (305.): so, in the Scarlatina, when 
the state of the fever and the appearances of the fauces 
render the nature of the disease ambiguous, bleeding 
may be omitted ; and, if not altogether avoided, it should 
at least not be large; and ought not to be repeated.* 

660. Vomiting, and especially nauseating doses of 
emetics, notwithstanding the inflamed state of the 
fauces, have been found very useful in this disease. 
An open belly is proper in every form of this disease; 
and when the nauseating doses of emetics operate a 
little downwards they are more serviceable.! 

661. Fn every form of the Scarlatina Anginosa, 
through the whole course of it, detergent gargles should 
be employed, and more or less as the quantity of 



* In most cases of Scarlatina Anginosa, that are, in any measure, severe, 
blood-letting constitutes an important remedy: in many, it may be several 
times repeated with advantage In the United States, where the type of 
this disease is, perhaps, more inflammatory than in Great Britain, it is very 
seldom other than a safe remedy. 

When the affection of the throat is troublesome, blistering externally 
should never be omitted ; the febrile action being previously reduced by 
evacuating remedies. 

f Emetics, particularly at the commencement of the disease, are highly 
useful. They relieve the stomach, determine to the skin, and break, in 
some measure, or, at least, weaken, the chain of diseased action, wherein 
the malady consists. In nauseating doses, they serve, in part, as a substitute 
for blood-lettiner. 



PRACTICE OF PHYSIC. 397 

sloughs and the viscid mucus in the fauces may seem 
to require.* 

662. liven in the milder states of the Scarlatina An- 
ginosa, it has been common with practitioners to exhi- 
bit the Peruvian bark through the whole course of the 
disease; but we are assured, by much experience, that 
in such cases it may be safely omitted, though in cases 
any ways ambiguous it may not be prudent to neglect 
this remedy. 

663. The anasarcous swelling, which frequently fol- 
lows the Scarlatina Anginosa, seldom requires any re- 
medy; and, at least, the purgatives so much inculcated, 
and so commonly exhibited, soon take off the anasarca. 



chapter v. 

OF THE PLAGUE.f 

Sect. I. — Of the Phenomena of the Plague. 

€64 THE Plague is a disease which always arises 
from contagion; which affects many persons about the 

* Aqueous gargles are rendered sufficiently detergent, by proper admix- 
tures of vinegar, tincture of myrrh, or muriatic acid. The judicious em- 
ployment of such remedies, accelerates the cure of the topical affection. 
When the disease has terminated, and convalescence commenced, a mild, 
but nutritious diet, constitutes the most efficacious tonic that can be ad- 
ministered. 

f We have already observed, that we do not believe plague to be a con- 
tagious disease. Knowing that this opinion is, by most people, perhaps, re- 
garded as heterodox, we feel ourselves bound to give our reasons for enter- 
taining it. They are as follow : 

I. Plague has never been certainly propagated by inoculation. This is 
true, notwithstanding all that has been said to the contrary. The instances 
in which attempts at inoculation have been made, are reported in a manner 
so loose and unsatisfactory, that no inference, absolutely conclusive, can, in 
any way, be drawn from them. On the whole, however, they afford, to a 



398 PRACTICE OF PHYSIC. 

same time; proves fatal to great numbers; generally pro- 
duces fever; and, in most persons, is attended with bu- 
boes or carbuncles. 

mind accustomed to analysis, no evidence that the attempts ever succeeded. 
It is true, that persons who had been inoculated, afterwards sickened and 
died of the plague, lint, from the vague and uncircumstantial manner in 
which their cases are described, it is impossible to determine, whether the 
disease was contracted from inoculation, or from some other source. The 
latter supposition appears to us by far the most probable. 

II. There exists in plague no morbid glands, by which a specific poison 
might be secreted ; and, therefore, no source to supply the contagion. Bu- 
boes cannot be regarded as such, because they do not appear in every case 
of the disease; nor, when they do make their appearance, are they always 
converted into open sores : and carbuncles, which are, in fact, nothing but 
spots of gangrenous inflammation, occur, comparatively speaking, in but few 
cases of the disease. 

1IT. riague is a disease of circumscribed prevalence, whether it be consi- 
dered in relation to place or time. It spreads only in given situations, under 
particular circumstances, and at certain seasons of the year. In Constanti- 
nople, the cold of the winter, and in Egypt, the heat and dryness of the sum- 
mer, completely check it. 

But this is not the character of a contagious disease. Contagion, as for- 
merly stated, is a secreted poison : it may be, therefore, and actually is, 
formed, indifferently, at every season, and in every situation — in the winter 
and summer, as well as in the spring or autumn ; in the country, as well as 
in cities ; in elevated regions, as readily as in low ones ; and, in every degree 
of latitude, from the line to the poles. Of the truth of this, small-pox, cow- 
pox, and lues venera, afford conclusive evidence. 

IV. If a case of plague be removed from the vitiated atmosphere, where 
the disease prevails, to a situation where the air is entirely free from septic 
effluvia, it is never communicated to physicians or visitants, nurses, or attend- 
ants. This fact appears to be as conclusively established as any one em- 
braced in the history of the disease. It is confirmed even by the writings of 
Dr. Russell himself, the great apostle of pestilential contagion. Plague, 
then, will not spread without the limits of a contaminated atmosphere; and 
is, hence, most palpably an atmospheric disease. 

How different is the case in relation to small-pox, to the spreading of which 
every condition of the air is equally favourable ! The reason is obvious. This 
disease depends for its propagation on a specific poison, generated by mor- 
bid action, which that poison itself excites. The action of this virus the 
condition of the air can neither assist nor prevent. 

But plague depends, for its existence, on a contaminated atmosphere ; and 
dies for want of nourishment if the air be pure. 

Nothing appears to us to be more truly absurd, than to contend for the con- 
tagious nature of a disease of this description. Real febrile contagion is a 
poison as absolute and independent as opium or henbane, arsenic or corro- 



PRACTICE OF PHYSIC. 399 

665. These are the circumstances, which, taken to- 
gether, give the character of the disease; but it is ac- 
companied with many symptoms almost peculiar to it- 
self, that, in different persons, are greatly diversified in 
number and degree, and should be particularly studied. 
I would wish to lay a foundation for this; but think it 
unfit for a person who has never seen the disease to 
attempt its particular history. For this, therefore, I 
must refer to the authors who have written on the sub- 
ject; but allowing those only to be consulted, who have 
themselves seen and treated the disease in all its differ- 
ent forms. 

666. From the accounts of such authors, it appears 
to me, that the circumstances which particularly distin- 
guish this disease, and especially the more violent and 
dangerous states of it, are, 

1st, The great loss of strength in the animal func- 
tions, which often appears early in the disease. 

2dly, The stupor, giddiness, and consequent stagger- 
ing, which resembles drunkenness, or the headach, and 
various delirium: which are all of them symptoms de- 
noting a great disorder in the functions of the brain. 

3e%, The anxiety, palpitation, syncope, and especial- 
ly the weakness and irregularity of the pulse, which 
denote a considerable disturbance in the action of the 
heart. 

Mhhj, The nausea and vomiting, particularly the vo- 
miting of bile, which shows an accumulation of vitiated 
bile in the gall-bladder and biliary ducts, and from 
thence derived into the intestines and stomach; all of 

sive sublimate ; and operates as exclusively by its own powers. As well, 
therefore, might we represent either of the latter to be capable of acting 
only under the influence of a given condition of the atmosphere, as the for- 
mer. The very idea of a poison pre-supposes an inherent and self-depend- 
entpower to act deleteriously : and this definition applies to the poison of 
contagion, as well as to every other. 



400 PRACTICE OF PHYSIC. 

which symptoms I suppose to denote a considerable 
spasm, and loss of lone, in the extreme vessels on the 
surface of the body. 

5thly, The buboes or carbuncles, which denote an 
acrimony prevailing in the fluids. And, 

Lastly, The petechias, ha3morrhagies, and colliqua- 
tive diarrhoea, which denote a putrescent tendency pre- 
vailing to a great degree in the mass of blood.* 

667. From the consideration of all these symptoms, 
it appears, that the plague is especially distinguished by 
a specific contagion, often suddenly producing the most 
considerable symptoms of debility in the nervous sys- 
tem or moving powers, as well as of a general putres- 
cency in the fluids; and it is from the consideration of 
these circumstances as the proximate cause, that I think 
both the prevention and cure of the plague must be di- 
rected. 

668. If this disease should revisit the northern parts 
of Europe, it is probable, that, at the time, there will 
be no physician then alive, who, at the first appearauce 

* We think our author's exposition of the pathology, or ratio symptoma- 
tum, of plague, which he attempts in this article, highly exceptionable. 

" The stupor, giddiness, and consequent staggering," with the " head- 
ach and various delirium," which he considers as " denoting a great disorder 
in the functions of the brain ;" " the anxiety, palpitation, syncope, and the 
weakness and irregularity of the pulse, which denote," as bethinks, "adis- 
turbance in the action of the heart ;'' " the buboes and carbuncles," which 
he derives from a prevailing acrimony in the blood ; and " the petechia, 
hemorrhagies, and colliquative diarrhoea, which denote," as he alleges, "a 
putrescent tendency prevailing to a great degree in the mass of blood"— all 
these symptoms, instead of being explicable on the professor's principles, 
may be much more fairly and rationally attributed to an inflamed, or other- 
wise highly disordered, condition of the stomach. We well know, that 
symptoms of the foregoing description, may originate in such a condition of 
the stomach, and, we feel persuaded, that, in the present instance, such is 
their source. Indeed, we are convinced, that the more accurately the plague 
and the yellow fever shall be examined, the more they will be found to re- 
semble, in their pathology, a species of gastrins. 

We might here repeat what we have already observed, that pestis vera be- 
longs more properly to the order phlegmasia:, than to that of exanthemata 



PRACTICE OF PHYSIC. 401 

of the disease, can be guided by his former experience, 
but must be instructed by his study of the writers on 
this subject, and by analogy. It is, therefore, I hope, 
allowable for me, upon the same grounds, to ofleiyhere 
my opinion with respect to both the prevention and 
cure of this disease. 

This paragraph was written before I had any notice 
of the plague of Moscow, anno 1771; but I think it 
will still apply to the case of Great Britain, and of many 
other northern states. 

Sect. II. — Of the Prevention of the Plague* 

669. With respect to the prevention: as we are firmly 
persuaded that the disease never arises in the northern 
parts of Europe, but in consequence of its being im- 
ported from some other country; so the first measure 
necessary, is the magistrate's taking care to prevent the 
importation: and this may generally be done by a due 
attention to bills of health, and to the proper perform- 
ance of quarantines. 

670. With respect to the latter, we are persuaded, 
that the quarantine of persons may safely be much less 
than forty days; and, if this were allowed, the execution 
of the quarantine would be more exact and certain, as 
the temptation to break it would be in a great measure 
removed. 

671. With respect to the quarantine of goods, it 
cannot be perfect, unless the suspected goods be un- 
packed and duly ventilated, as well as the other means 

* As we do not believe in the communicability of plague, by means of 
contagion, it would be superfluous in us to offer any remarks on our au- 
thor's mode of prevention, which is founded entirely on that hypothesis. 
Considered as a means of accomplishing what he intends, we should only 
deny the propriety of the whole. Yet, for the avoidance of a disease arising 
from a poison commingled with the atmosphere, many of his directions are 
pertinent and useful. 

VOL. I. 3 E 



402 PRACTICE OF PHYSIC. 

employed for correcting the infection they may carry, 
and, if all this were properly done, it is probable that 
the time commonly prescribed for the quarantine of 
goods might also be shortened. 

672. A second measure, in the way of prevention, 
becomes requisite, when an infection has reached and 
prevailed in any place, to prevent that infection from 
spreading into other places. This can be done only by 
preventing the inhabitants, or the goods of any infected 
place, from going out of it, till they have undergone a 
proper quarantine. 

673. The third measure for prevention, to be em- 
ployed with great care, is to hinder the infection from 
spreading among the inhabitants of the place in which 
it has arisen. The measures necessary for this, are to be 
directed by the doctrine laid dowmin 82.", and from that 
doctrine we infer, that all persons who can avoid any 
near communication with infected persons, or goods, 
may escape the infection. 

674. For avoiding such communication, a great deal 
may be done by the magistrate: 1. By allowing as many 
of the inhabitants as are free from the infection, and not 
necessary to the service of the place, to go out of it. 
2. By prohibiting all assemblies, or unnecessary inter- 
course of the people. 3. By taking care that necessary 
communications be performed without contact. 4. By 
making such arrangements and provisions as may ren- 
der it easy for the families remaining to shut themselves 
up in their own houses. 5. By allowing persons to quit 
houses in which an infection appears, upon condition 
that they go into lazarettoes. 6. By ventilating and pu- 
rifying, or destroying, at the public expense, all infected 
goods. Lastly, by avoiding hospitals, and providing se- 
parate apartments for infected persons. 

The execution of these measures will require great 



PRACTICE OF PHYSIC. 403 

authority, and much vigilance and attention, on the part 
of the magistrate; but it is not our province to enter 
into any detail on this subject of the public police. 

675. The fourth and last part of the business of pre- 
vention respects the conduct of persons necessarily re- 
maining in infected places, especially of those obliged to 
have some communication with persons infected. 

676. Of those obliged to remain in infected places, 
but not obliged to have any near communication with 
the sick, they may be preserved from the contagion by 
avoiding all near communication with other persons, or 
their goods; and it is probable that a small distance will 
answer the purpose, if, at the same time, there be no 
stream of air to carry the effluvia of persons, or goods, 
to some distance. 

677. For those who are necessarily obliged to have a 
near communication with the sick, it is proper to let 
them know, that some of the most powerful contagions 
do not operate, but when the bodies of men exposed to 
the contagion are in certain circumstances which ren- 
der them more liable to be affected by it; and, there- 
fore, by avoiding these circumstances and causes, they 
may often escape infection. 

678. The bodies of men are especially liable to be 
affected by contagions, when they are any ways consi- 
derably weakened by want of food, and even by a scanty 
diet, or one of little nourishment; by intemperance in 
drinking, which, when the stupor of intoxication is 
over, leaves the body in a weakened state; by excess in 
venery; by great fatigue; or by any considerable eva- 
cuation. 

679. The causes which, concurring with contagion, 
render it more certainly active, are cold, fear, and full 
living. 

The several means, therefore, of avoiding or guard- 



101 PRACTICE OF PHYSIC. 

ing against the action of cold (94. to, 9G.) arc to be 
carefully studied. 

680. Against fear the mind is to be fortified as well 
as possible, by inspiring a favourable idea of the power 
of preservative means; by destroying the opinion of the 
incurable nature of the disease; by occupying men's 
minds with business or labour; and by avoiding all ob- 
jects of fear, as funerals, passing bells, and any notice 
of the death of particular friends. 

681. A full diet of animal food increases the irritabi- 
lity of the body, and favours the operation of conta- 
gion; and indigestion, whether from the quantity or qua- 
lity of food, has the same effect. 

682. Besides giving attention to obviate the several 
circumstances (609. 678. to 681.) which favour the 
operation of contagion, it is probable that some means 
may be employed for strengthening the bodies of men, 
and thereby enabling them to resist contagion. 

For this purpose, it is probable, that the moderate 
use of wine, or of spirituous liquors, may have a good 
effect. 

It is probable also, that exercise, when it can be em- 
ployed, if so moderate as to be neither heating nor 
fatiguing to the body, may be employed with advantage. 

Persons who have tried cold bathing, and commonly 
feel invigorating effects from it, if they are any ways 
secure against having already received infection, may 
possibly be enabled to resist it by the use of the cold 
bath. 

It is probable, that some medicines also may be use- 
ful in enabling men to resist infection; but amongst 
these I can harldy admit the numerous alexipharmics 
formerly proposed; or, at least, very few of them, and 
those only of tonic power. Amongst these last we 
reckon the Peruvian bark; and it is perhaps the 



PRACTICE OF PHYSIC. 405 

most effectual. If any thing is to be expected from 
antiseptics, I think camphire, whether internally or ex- 
ternally employed, is one of the most promising. 

Every person is to be indulged in the use of any 
means of preservation of which he has conceived a 
good opinion, whether it be a charm or a medicine, if 
the latter be not directly hurtful. (* 

Whether issues be useful in preserving from, or in 
moderating the effects of contagion, I cannot determine 
from the observations I have yet read. 

683. As neither the atmosphere in general, nor any 
considerable portion of it, is tainted or impregnated 
with the matter of contagions; so the lighting of fires 
over a great part of the infected city, or other general 
fumigations in the open air. are of no use for preventing 
the disease, and may perhaps be hurtful. 

684. It would probably contribute much to check 
the progress of infection, if the poor were enjoined 
to make a frequent change of clothing, and were suita- 
bly provided for that purpose, and if they were, at the 
same time, induced to make a frequent ventilation of 
their houses and furniture. 

Sect. Ill— Of the Cure of the Plague/" 

685. In the cure of the plague, the indications are 
the same as those of fever in general (126.); but here 
they are not all equally necessary and important. 

• To venture on directing the details of practice, in a disease wherein 
we have no experience, would betray in us a degree of self-confidence, 
wh.ch we do not feel. But, of the general indications, we will venture to 
speak 

These, from the best view we can take of the disease, appear to be, to 
moderate excessive action, or sustain declining strength, according to the 
anting state of the system; to evacuate freely the stomach and bowels, en- 
deavourmg thus to alter the state of morbid action in the alimentary canal, 
and to determine to the surface 



406 PRACTICE OF PHYSIC. 

686. The measures for moderating the violence oi 
reaction, which operate by diminishing the action oi 
the heart and arteries (128.), have seldom any place 
here; excepting so far as the antiphlogistic regimen is 
generally proper. Some physicians, indeed, have re- 
commended bleeding-, and there may occur cases in 
which bleeding may«be useful ; but, for the most part, 
it is unnecessary, and, in many cases, it might be very 
hurtful. 

Purging has also been recommended; and, in some 
degree, it may be useful, in drawing off the bile, or 
other putrescent matters, frequently present in the in- 
testines; but a large evacuation this way may certainly 
be hurtful. 

687. The moderating the violence of reaction, so far 
as it can be done by taking off the spasm of the ex- 
treme vessels, (151.) is a measure of the utmost neces- 
sity in the cure of the plague; and the whole of the 
means (152. to 200.) suited to this indication are ex- 
tremely proper. 

688. The giving an emetic at the very first approach 
of the disease, would probably be of great service; and 
it is likely, that at some other periods of the disease, 
emetics might be useful, both by evacuating bile abun- 
dant in the alimentary canal, and by taking off the spasm 
of the extreme vessels. 

To answer these indications, the appropriate remedies must be adminis- 
tered. For the two first, suitable evacuations, or stimulants, cordials, and 
other articles of nourishment. For the third, vomiting and purging; and, 
for the fourth, sudorifics, rubefacients, and blisters, when they can be ap- 
plied without endangering the production of gangrene. 

The cold bath, when it proves useful in this disease, must do so, by de- 
termining to the surface. 

Such we believe to be the chief indications for the treatment of plague ; 
and such the cardinal remedies to be used in it; which it belongs to the 
practitioner to persevere in, or vary, according to the dictates of his judg- 
ment, and the result of his experience. 



PRACTICE OF PHYSIC. 407 

689. From some principles with respect to fever in 
general, and with respect to the plague in particular, I 
am of opinion, that, after the exhibition of the first vo- 
mit, the body should be disposed to sweat; which ought 
to be raised to a moderate degree only, but continued 
for at least twenty-four hours, or longer if the patient 
bear it easily. 

690. This sweating should be excited and con- 
ducted agreeably to the rules laid down in 168. It is 
to be promoted by the plentiful use of diluents, ren- 
dered more grateful by vegetable acids, or more pow- 
erful by being impregnated with some portion of neu- 
tral salts. 

691. To support the patient under the continuance 
of the sweat, a little weak broth, acidulated with the 
juice of lemons, may be given frequently; and some- 
times a little wine, if the heat of the body be not con- 
siderable. 

692. If sudorific medicines are judged to be neces- 
sary, opiates are the most effectual and safe: but they 
should not be combined with aromatics; and probably 
may be more effectual if joined with a portion of emetics, 
and of neutral salts. 

693. If, notwithstanding the use of emetics and su- 
dorifics, the disease should still continue, the cure 
must depend upon the employment of means for obvi- 
ating debility and putrescency; and for this purpose, 
the various remedies proposed above, (from 201. to 
221.) may all be administered, but especially the to- 
nics; and of these the chief are cold drink and the Pe- 
ruvian bark. 

694. In the cure of the plague, some attention is 
due to the management of buboes and carbuncles; but 
we do not touch this, as it belongs to the province of 
surgery. 



408 PRACTICE OF PHYSK 

CHAPTER VI. 

OF ERYSIPELAS, OR ST. ANTHONY'S FIRE. 

695. IN 274, I mentioned the distinction which I pro- 
posed to make between the diseases to be named the 
Erythema and the Erysipelas; and from thence it will 
appear that Erysipelas, as an Erythema following fever, 
may have its place here. 

696. I suppose the Erysipelas to depend on a mat- 
ter generated within the body, and which, analogous to 
the other cases of exanthemata, is in consequence of fe- 
ver thrown out upon the surface of the body. I own 
it may be difficult to apply this to every particular case 
of Erysipelas: but I take the case in which it is gene- 
rally supposed to apply, that of the Erysipelas of the 
face; which I shall therefore consider here.* 

* This, like most other diseases of the skin, appears to have its seat in the 
stomach. At the commencement of erysipelas of the face, that organ is 
known to be oftentimes very much affected. Hence, the free evacuation of 
the alimentary canal is a measure of great importance, in the treatment of 
that disease. 

Erysipelas of the face, moreover, possesses many points of strong resem- 
blance to gout. In fact, it is oftentimes nothing but a modification of gout; 
which, as we have already represented, has its origin in the stomach. 

Some of the points of resemblance between gout and erysipelas of the 
face are, that these diseases occur, not only in subjects of the same descrip- 
tion, but in the same individuals, and even, occasionally, alternate with each 
other. We are intimate with a gentleman, of a gouty diathesis, whose pa- 
roxysms have several times commenced in the form of erysipelas of the 
face, and terminated in regular podagra. Other instances of the same kind 
we know to have occurred. 

Females, about the termination of their menstrual period, are particularly 
liable to erysipelas of the face. In them, we believe it to be, oftentimes, at 
least, nothing but a substitute for another form of gout 

Impressed by these considerations, we cannot but regard it as a very pal- 
pable error in Dr. Cullen, to have introduced erysipelas into his order exan- 
themata. It undoubtedly belongs to that of phlegmasiw, as the professor 
himself finds cause to acknowledge. 



PRACTICE OF PHYSIC. 409 

097. The Erysipelas of the face comes on with a cold 
shivering, and other symptoms of the pyrexia. The hot 
stage of this is frequently attended with a confusion of 
head and some degree of delirium; and almost always 
with drowsiness, and perhaps cOma. The pulse is al- 
ways frequent, and commonly full and hard. 

G98. When these symptoms have continued for one, 
two, or at most three days, there appears, on some 
part of the face, a redness, such as that described in 
215. as the appearance of Erythema. This redness, 
at first, is of no great extent; but gradually spreads from 
the part it first occupied to the other parts of the face, 
commonly till it has affected the whole; and frequently 
from the face it spreads over the hairy scalp, or de- 
scends on some part of the neck. As the redness 
spreads, it commonly disappears, or at least decreases, 
in the parts it had before occupied. All the parts upon 
which the redness appears are, at the same time, affected 
with some swelling, which continues for some time after 
the redness has abated. The whole face becomes con- 
siderably turgid; and the eye-lids are often so much 
swelled as entirely to shut up the eyes. 

699. When the redness and swelling have proceeded 
for some time, there commonly arise, sooner or later, 
blisters of a larger or smaller size, on several parts of 
the face. These contain a thin yellowish, or almost 
colourless liquor, which sooner or later runs out. The 
surface of the skin, in the blistered places, sometimes 
becomes livid and blackish; but this livor seldom goes 
deeper than the surface, or discovers any degree of gan- 
grene affecting the skin. On the parts of the face not 
affected with blisters, the cuticle suffers, towards the 
end of the disease, a considerable desquamation. Some- 
times the tumour of the eye-lids ends in a suppuration. 

700. The inflammation coming upon the face does 
vol. i. 3 F 



UO PRACTICE OF PHYSIC. 

not produce any remission of the fever which had be- 
fore prevailed; and sometimes the fever increases with 
the increasing and spreading inflammation. 

701. The inflammation usually continues for eight or 
ten days; and, for the same time, the fever and symp- 
toms attending it also continue. 

702. In the progress of the inflammation the delirium 
and coma attending it sometimes go on increasing, and 
the patient dies apoplectic on the seventh, ninth, or 
eleventh day of the disease. In such cases it has been 
commonly supposed that the disease is translated from 
the external to the internal parts. But I have not seen 
any instance in which it did not appear to me, that the 
affection of the brain was merely a communication of 
the external affection, as this continued increasing at 
the same time with the internal. 

703. When the fatal event does not take place, the 
inflammation, after having affected a part, commonly 
the whole of the face, and perhaps the other external 
parts of the head, ceases. With the inflammation, the 
fever also ceases; and without any evident crisis, the pa- 
tient returns to his ordinary state of health. 

704. This disease is not commonly contagious; but 
as it may arise from an acrid matter externally applied, 
so it is possible that the disease may sometimes be com- 
municated from one person to another. 

Persons who have once laboured under this disease 
are liable to returns of it* 

705. The event of this disease may be foreseen from 
the state of the svmptoms, which denote more or less 
affection of the brain. If neither delirium nor coma 
come on, the disease is seldom attended with any dan- 
ger; but when these symptoms appear early in the dis- 

* This disease does not exhibit a mark of contagion more than intermitting 
. rheumatism, or peripneumony. 



PRACTICE OF PHYSIC. 411 

ease, and are in a considerable degree, the utmost dan- 
ger is to be apprehended. 

706. As this disease often arises in the part, at the 
same time with the coming on of the pyrexia; as I have 
known it, with all its symptoms, arise from an acrimony 
applied to the part; as it is commonly attended with a 
full and frequently a hard pulse; as the blood drawn in 
this disease shows the same crust upon its surface, that 
appears in the phlegmasia?; and, lastly, as the swelling 
of the eye-lids, in this disease, frequently ends in suppu- 
ration; so, from these considerations, it seems doubtful 
if this disease be properly, in Nosology, separated from 
the Phlegmasia?. At any rate, I take the disease I have 
described to be what physicians have named the Ery- 
sipelas Phlegmonodes, and that it partakes a great deal 
of the nature of the Phlegmasia?. 

707. Upon this conclusion, the Erysipelas of the face 
is to be cured very much in the same maimer as phleg- 
monic inflammation, by blood-letting, cooling purgatives, 
and by employing every part of the antiphlogistic regi- 
men; and our experience has confirmed the fitness of 
this method of cure. 

708. The evacuations of blood-letting and purging are 
to be employed more or less, according to the urgency 
of symptoms, particularly those of the pyrexia, and of 
those which mark an affection of the brain. As the 
pyrexia continues and often increases with the inflam- 
mation of the face, so the evacuations mentioned may 
be employed at any time in the course of the disease.* 

709. In this, as in other diseases of the head, it is 



* Copious purging is a most important remedy in this disease. So is 
blood-letting, carried, in many instances, to a considerable extent, and seve- 
ral times repeated. In very threatening cases, nearly a hundred ounces of 
bloo.l have been taken away, in a few days, with great advantage. Usually, 
however, the quantity necessary to be drawn is much less. 



412 PRACTICE OF PHYSIC. 

proper to put the patient, as often as he can easily bear 
it, into somewhat of an erect posture* 

710. As in this disease there is always an external 
affection, and as in many instances there is no other; 
so various external applications to the part affected 
have been proposed; but almost all of them are of doubt- 
ful effect. The Narcotic, refrigerant, and astringent 
applications, are suspected of disposing to gangrene; 
spirituous applications seem to increase the inflamma- 
tion; and all oily or watery applications seem to occa- 
sion its spreading. The application that seems most 
safe, and which is now most commonly employed, is 
that of a dry mealy powder frequently sprinkled upon 
the inflamed parts.f 

711. An Erysipelas Phlegmonodes frequently ap- 
pears on other parts of the body, beside the face; and 
such other erysipelatous inflammations frequently end 
in suppuration. These cases are seldom dangerous. 
At coming on, they are sometimes attended with drow- 

* It is advisable to keep the head of the patient somewhat elevated in this 
complaint — as much so, at least, as is agreeable to his feelings: but, in no 
dangerous febrile affection, can an erect posture of the body be either useful 
or admissible. In such a case, the stimulus of muscular exertion should be 
carefully avoided. In laying down his antiphlogistic plan of treatment, Dr. 
Cullen himself very properly gives a particular and strong injunction to this 
effect. 

| A very common and grateful application in this disease, is that of oat- 
meal or rye-flour, frequently repeated. It is to be lightly sprinkled on the 
part, and when it becomes warm, carefully wiped off and renewed. It allays 
the itching and burning, which are so troublesome and distressing, and com- 
municates an agreeable sensation of coolness. 

But nothing, we believe, so effectually checks the progress o'f erysipela- 
tous inflammation, as the use of blisters. When the inflamed spot is so situ- 
ated, and of such a size, that it can be completely covered by a blister, it 
rarely extends any further. 

In erysipelas of the face we have never employed this remedy. But, for 
arresting the course of this disease, v.'hcn affecting other parts of the body, 
we have repeatedly used it, with great advantage. In what our author de- 
nominates "erysipelas phlegmonodes" of the limbs, it should never be ne 
gjectedi 



PRACTICE OF PHYSIC. £1$ 

siness, and even with some delirium; but this rarely 
happens; and these symptoms do not continue after the 
inflammation is formed. I have never seen an instance 
of the translation of this inflammation from the limbs 
to an internal part; and though these inflammations of 
the limbs be attended with pyrexia, they seldom require 
the same evacuations as the erysipelas of the face. At 
first they are to be treated by dry mealy applications 
only; and all humid applications, as fomentations, or 
poultices, are not to be applied, till, by the continuance 
of (he disease, by the increase of swelling, or by a 
throbbing felt in the part, it appears that the disease is 
proceeding to suppuration. 

712. We have hitherto considered erysipelas as in 
a great measure of a phlegmonic nature; and agreeably 
to that opinion, we have proposed our method of cure. 
But it is probable, that an erysipelas is sometimes at- 
tended with, or is a symptom of, a putrid fever; and, in 
such cases, the evacuations proposed above may be im- 
proper, and the use of the Peruvian bark may be neces- 
sary; but I cannot be explicit upon this subject, as such 
putrid cases have not come under my observation. 



CHAPTER VII. 
OF THE MILIARY FEVER.* 

713. 1 HIS disease is said to have been unknown to 
the ancients, and that it appeared, for the first time, in 

• Very fortunately, the form of fever treated of in this chapter is but little 
known in the United States. We are yet to be convinced that it is knowfl 
at all. As to ourselves, we do not recollect ever to have seen a decided 
case ef it. With our author, we are apprehensive that it is always the re 
wit of injudicious treatment. It arises from the action of an excess 



414 PRACTICE OF PHYSIC. 

Saxony, about the middle of the last century. It is 
said to have spread from thence into all the other parts 

ternal heat, and internal stimulants— more especially the latter: for, like 
other diseases of the skin, it is of gastric origin. To the alexipharmic and 
heating regimen generally, once so fashionable in the treatment of fever, in 
Europe, but which never found its way, in strength, across the Atlantic, is 
(he existence of this complaint to be chiefly attributed. That regimen was 
pursued more especially in the case of lying-in women, and hence the rea- 
son, why these subjects were most liable to miliary fever. Even among 
ourselves, and, at the present day, females, in this situation, are frequently 
injured by the use of an inflammatory preparation denominated caudle. 

We have seen eruptions of the miliary kind produced by an indiscreet 
and extravagant use of pepper mixed in ardent spirits, for the cure of inter- 
mitting fever. Large and repeated doses of spirits of turpentine have been 
known to be productive of a similar effect. Even the bark itself, unskilfally 
administered, during the existence of fever, has often given rise to cuta- 
neous eruptions. About the mouth, these eruptions are by no means un- 
common, and are precursory, for the most part, to the disappeaitnce of the 
complaint. 

The perspirable matter, confined on the skin, by an excess of covering, 
stimulates by its acrimony, and aids in the production of the disease we are 
considering. 

When the miliary fever does occur, we believe, with our author, that the 
propertreatment of it consists in a cooling regimen ; to which should be add- 
ed, provided the patient's strength be sufficient to bear it, the use of 
emetics and active purgatives. But the proper practice is, to prevent this 
disease, by an avoidance of the causes which are known to produce it — a 
measure, for the neglect of which, we are altogether inexcusable, in as much 
as those causes are perfectly under our control. We feel persuaded, that 
at no very distant period, when the treatment of diseases shall be conducted 
on more enlightened and rational principles, miliary fever will be recog- 
nized only by name, as a memorial of the errors of earlier times. 

Among the multiplied forms and varieties of epidemics, it is altogether 
possible, that some may appear, marked by extensive miliar}' eruptions, in- 
dependently of the influence of the causes we have enumerated. In case of 
the occurrence of such an event, the disease will be found to be of gastric 
origin, and the principal remedies in the treatment of it, will be, vomiting, 
purging, and, perhaps, blood-letting. The complaint may, however, as- 
sume a typhous character, when the latter remedy will, of course, be inad- 
missible. 

A superabundant acidity in the stomach proves sometimes the cause of, 
or at least, accompanies, cutaneous eruptions. In this case, alkalis and ab- 
sorbents are useful remedies Tonics must also be administered, to remove 
the weakness and want of digestive power, from which the acidity arises. 

If, in miliary fever, a retrocession of the eruption take place or be 
strongly threatened, sudorifics and blisters are the remedies by which the 
evil should be met. In this case, cold and, perhaps* even cool air should be 



PRACTICE OF PHYSIC. 415 

of Europe; and, since the period mentioned, to have 
appeared in many countries in which it had never ap- 
peared before. 

714. From the time of its having been first particu- 
larly observed, it has been described and treated of by 
many different writers; and by all of them, till very late- 
ly, has been considered as a peculiar idiopathic disease. 

It is said to have been constantly attended with pe- 
culiar symptoms. It comes on with a cold stage, which 
is often considerable. The hot stage which succeeds, 
is attended with great anxiety, and frequent sighing. 
The heat of the body becomes great, and soon pro- 
duces profuse sweating; preceded, however, by a sense 
of pricking, as of pin-points in the skin; and the sweat 
is of a peculiarly rank and disagreeable odour. The 
eruption appears sooner or later in different persons, 
but at no determined period of the disease. It seldom 
or never appears on the face; but discovers itself first 
upon the neck and breast, and from thence often 
spreads over the whole body. 

715. The eruption named Miliary is said to be of 
two kinds, the one named the Red, the other the White 
Miliary. The former, which in English is strictly named 
the Rash, is commonly allowed to be a symptomatic af- 
fection; and as the latter is the only one that has any 
pretensions to be considered as an idiopathic disease, it 
is this alone that I shall more particularly describe and 
treat of in the present chapter. 

carefully avoided. An emetic may avert or remove the mischief, by alter- 
ing the condition of the stomach — the probable cause of the retrocession — 
and determining to the surface. Convulsions, under these circumstances, 
must be extremely dangerous. If they occur, bleeding, blistering and in- 
jections will be necessary. Perhaps an anodyne injection may afford relief, 
as it frequently does in convulsions from other causes. 

With these remarks we dismiss the subject, leaving to our readers to ac- 
quire a knowledge of the history of miliary fever from the text of our au- 
thor. 



ilG PRACTICE OF PHYSIC. 

716. What then is called the White Miliary eruption 
appears at first like the red, in very small red pimples, 
for the most part distinct, but sometimes clustered to- 
gether. Their slight prominence is distinguished better 
by the finger than by the eye. Soon after the appear- 
ance of this eruption, and at least on the second day, 
a small vesicle appears upon the top of each pimple. 
At first the vesicle is whey-coloured; but soon becomes 
white, and stands out like a globule on the top of the 
pimple. In two or three days, these globules break, or 
are rubbed off; and are succeeded by small crusts, 
which soon after fall off in small scales. While one set 
of pimples takes this course, another set succeeds; so 
that the disease often continues upon the skin for many 
days together. Sometimes when one crop of this erup- 
tion has disappeared, another, after some interval, is 
produced. And it has been further observed, that in 
some persons there is such a tendency to this disease, 
that they have been affected with it several times, in the 
course of their lives. 

717. This disease is said to affect both sexes, and 
persons of all ages and constitutions; but it has been 
observed, at all times, to affect especially, and most fre- 
quently, lying-in women. 

718. This disease is often accompanied with violent 
symptoms, and has frequently proved fatal. The symp- 
toms attending it are, however, very various. They are, 
in one or other instances, all the several symptoms at- 
tending febrile diseases; but I cannot find that any symp- 
tom or course of symptoms are steadily the same in dif- 
ferent persons, so as to furnish any specific character to 
the disease. When the disease is violent, the most com- 
mon symptoms are phrenitic, comatose, and convulsive 
affections, which are also symptoms of all fevers treated 
by a very warm regimen. 



PRACTICE OF PHYSIC. 417 

719. While there is such a variety of symptoms ap- 
pearing in this disease, it is not to be expected that any 
one particular method of cure can be proposed: and ac- 
cordingly we find, in different writers, different methods 
and remedies prescribed; frequent disputes about the 
most proper; and those received and practised by some, 
opposed and rejected by others. 

720. I have thus given an account of what I have 
found delivered by authors who have considered the 
white miliary fever as an idiopathic disease: but, now, 
after having often observed the disease, I must say that 
I doubt much if it ever be such an idiopathic, as has 
been supposed, and I suspect that there is much fallacy 
in what has been written on the subject. 

721. It seems to me very improbable, that this should 
have been really a new disease when it was first con- 
sidered as such. There appear to me very clear traces 
of it in authors who wrote long before that period; and, 
though there were not, we know that the descriptions 
of the ancients were inaccurate and imperfect, particu- 
larly with respect to cutaneous affections; whilst we 
know also very well, that those affections which usually 
appear as symptomatic only, were commonly neglected, 
or confounded together under a general appellation. 

722. The antecedent symptoms of anxiety, sighing, 
and pricking of the skin, which have been spoken of as 
peculiar to this disease, are, however, common to many 
others; and, perhaps to all those in which sweatings are 
forced out by a warm regimen. 

Of the symptoms said to be concomitant of this erup- 
tion, there are none which can be said to be constant and 
peculiar but that of sweating. This, indeed, always pre- 
cedes and accompanies the eruption; and, while the 
miliary eruption attends many different diseases, it ne- 
ver, however, appears in any of these, but after sweat- 

vol. i. 3 G 



418 PRACTICE OF PHYSIC. 

ing; and, in persons labouring under these diseases, it 
does not appear, if sweating be avoided. It is tin 
fore probable, that the eruption is the effect of sweat- 
ing; and that it is the produce of a matter, not before 
prevailing in the mass of blood, but generated, under 
particular circumstances, in the skin itself. That it 
depends upon particular circumstances of the skin, ap- 
pears further from hence, that the eruption seldom or 
never appears upon the face, although it affects the 
whole of the body besides; that it comes upon those 
places especially which are more closely covered; and 
that it can be brought out upon particular parts by ex- 
ternal applications. 

723. It is to be observed, that this eruptive disease 
differs from the other exanthemata in many circum- 
stances; in its not being contagious, and therefore ne- 
ver epidemic; that the eruption appears at no deter- 
mined period of the disease; that the eruption has no 
determined duration; that successive eruptions fre- 
quently appear in the course of the same fever; and that 
such eruptions frequently recur in the course of the 
same person's life. 

All these circumstances render it extremely probable, 
that, in the miliary fever, the morbific matter is not a 
subsisting contagion communicated to the blood, and 
thence, in consequence of fever and assimilation, thrown 
out upon the surface of the body; but a matter occa- 
sionally produced in the skin itself, by sweating. 

724. This conclusion is further rendered probable, 
from hence, that, while the miliary eruption has no pe- 
culiar symptoms, or concourse of symptoms, belonging 
to it; yet, upon occasion, it accompanies almost all fe- 
brile diseases, whether inflammatory or putrid, if these 
happen to be attended with sweating; and from thence 
it may be presumed^ that the miliary eruption is a symp 



PRACTICE OF PHYSIC. 419 

tomatic affection only, produced in the manner we have 
said. 

125. But, as this symptomatic affection does not al- 
ways accompany every instance of sweating, it may be 
proper to inquire what are the circumstances which es- 
pecially determine this eruption to appear? To this, 
however, I can give no full and proper answer. I can- 
not say that there is any one circumstance which in all 
cases gives occasion to this eruption; nor can I say, what 
different causes may, in different cases, give occasion 
to it. There is only one observation I can offer to the 
purpose of this inquiry; and it is, that, of the persons 
sweating under febrile diseases, those are especially lia- 
ble to the miliary eruption, who have been previously 
weakened by large evacuations, particularly of blood. 
This will explain why it happens to lying-in women 
more frequently than to any other persons; and to con- 
firm this explanation, I have remarked, that the eruption 
happened to women not in child-bed, but who had been 
much subjected to a frequent and copious menstruation; 
and to an almost constant fluor albus. I have also had 
occasion to observe it happen to men in fevers, after 
wounds from which they had suffered a great loss of 
blood. 

Further, that this eruption is produced by a certain 
state of debility, will appear probable, from its often oc- 
curring in fevers of the putrid kind, which are always 
attended with great debility. It is true, that it also 
sometimes attends inflammatory diseases, when it cannot 
be accounted for in the same manner; but I believe it 
will be found to attend especially those inflammatory 
diseases in which the sweats have been long protracted 
or frequently repeated, and which have thereby pro- 
duced a debility, and perhaps a debilitating putrid dia- 
thesis. 



1,20 PRACTICE OF PHYSIC. 

726. It appears so clearly to me, that this eruption 
is always a symptomatic and factitious affection, that 
I am persuaded it may be in most cases prevented 
merely by avoiding sweats. Spontaneous sweatings, in 
the beginning of diseases, are very rarely critical; all 
sweatings, not evidently critical, should be prevented; 
and the promoting them, by increasing external heat, 
is commonly very pernicious. Even critical sweats 
should hardly be encouraged by such means. If, there- 
fore, spontaneous sweats arise, they are to be checked 
by the coolness of the chamber; by the lightness and 
coolness of the bed-clothes; by the person's laying out 
their hands and arms, and by their taking cold drink: 
and, by these precautions, I think I have frequently 
prevented miliary eruptions, which were otherwise like- 
ly to have appeared, particularly in lying-in women. 

727. But it may happen, when these precautions 
have been neglected, or from other circumstances, that 
a miliary eruption does actually appear; and the ques- 
tion will then be put, how the case is to be treated? It 
is a question of consequence, because I believe that 
the matter here generated is often of a virulent kind; 
it is frequently the offspring of putrescency^ and, when 
treated by increasing the external heat of the body, it 
seems to acquire a virulence which produces those 
symptoms mentioned in 718, and proves certainly fatal. 

It has been an unhappy opinion with most physicians, 
that eruptive diseases were readily to be hurt by cold; 
and that it was, therefore, necessary to cover up the 
body very closely, so as thereby to increase the external 
heat. We now know that this is a mistaken opinion; 
that increasing the external heat of the body is very 
generally mischievous; and that several eruptions not 
only admit, but require the application of cold air. We 
are now persuaded, that the practice which formerly 



PRACTICE OF PHYSIC. 421 

prevailed, in the case of miliary eruptions, of covering 
up the body close, and, both by external means, and 
internal remedies, encouraging the sweatings which ac- 
company this eruption, was highly pernicious, and 
commonly fatal. I am, therefore, of opinion, even 
when a miliary eruption has appeared, that in all cases 
where the sweating is not manifestly critical, we should 
employ all the several means of stopping it that are 
mentioned above; and I have sometimes had occasion 
to observe, that even the admission of cool air was safe 
and useful. 

728. This is, in general, the treatment of miliary 
eruptions; but, at the same time, the remedies suited 
to the primary disease, are to be employed: and, there- 
fore, when the eruption happens to accompany inflam- 
matory affections, and when the fulness and hardness 
of the pulse or other symptoms show an inflammatory 
state present, the case is to be treated by blood-letting, 
purging, and other antiphlogistic remedies. 

Upon the other hand, when the miliary eruption at- 
tends diseases in which debility and putrescency pre- 
vail, it will be proper to avoid all evacuations, and 
employ tonic and antiseptic remedies, particularly the 
Peruvian bark, cold drink, and cold air. 

I shall conclude this subject with mentioning, that 
the venerable octogenarian practitioner, de Fischer, 
when treating of this subject, in laying down the indi- 
cations of cure, has given this as one of them: " Excre- 
tionis periphericae non primariain habere rationem." 



122 PRACTICE OF PHYSIC. 



CHAPTER VIII. 

OF THE REMAINING EXANTHEMATA, 
URTICARIA, PEMPHIGUS, AND APHTHA.* 

729. THE Nettle Rash is a name applied to two dif- 
ferent diseases. The one is the chronic eruption de- 

* Although every malady is an evil which ought to be carefully prevented 
or removed, yet the diseases treated of in this chapter are, comparatively, 
of little moment. 

Of Pemphigus we have no knowledge, having never seen the complaint 
ourselves, nor read any account of it that is worthy of being remembered, 
much less reprinted. We shall, therefore, dismiss it without further notice. 
In the mean time, those who are curious on the subject, may consult Wil- 
lan, Dickson, (Transactions of the Royal Irish Academy for 1787,) and 
Thomas; from each of whom something may be learnt respecting this dis- 
ease. Although but little known in Europe, it is still, we believe, a much 
greater stranger in the United States. 

Urticaria, or Nettle-rash, has a place among the diseases of our country; 
but so mild is it in its nature, and so inconsiderable are the danger and in- 
convenience which accompany it, that physicians are but rarely consulted re- 
specting its treatment. 

It is more particularly a disease of youth, and occurs most frequently in 
the season of spring. The returning warmth of the atmosphere may have 
some influence in producing it; but most cases of it that we have witnessed, 
could be clearly traced to gastric irritation. We once saw it brought on by 
a diet of rich chocolate, in a youth who had just recovered from a severe 
attack of inflammatory fever. In other instances, we have been able to trace 
it to an immoderate use of pickles, spices, and acids. We lately attended 
an irregular case of it in a child of about four years old, which had been 
evidently induced by an inordinate meal of sour cherries. 

When it calls for remedies, the first and principal indication in the treat- 
ment of it is, to evacuate thoroughly the alimentary canal. This must be 
done by vomiting and purging. A solution of tartarized antimony and sul- 
phate of soda, constitutes, for this purpose, a valuable remedy. The for- 
mula is, an ounce of the latter, added to two or three gains of the former, to 
be exhibited in divided doses till it operate. 

If the disease, which is always, we believe, inflammatory, yield not to re- 
medies directed to the alimentary canal, we must resort to blood-letting. It 
is understood, that during our treatment of it, a strict observance of the an- 
tiphlogistic regimen is to be enjoined — in a more especial manner, an avoid- 



PRACTICE OF PHYSIC, 403 

scribed by Dr. Heberden in the Medical Transactions, 
vol. i. art. xvii. which, as not being a febrile disorder, 

ance of every thing that might irritate the stomach. The termination of 
Urticaria is always favourable. 

Aphtha or Thrush, commences also, we believe, in the stomach. In this 
country, it is very much a disease of childhood; although cases of it do 
occur in adults, whose stomach and bowels are irritable and weak. An epi- 
demic aphthous fever has nerer, to our knowledge, appeared in the United 
States. In Barbadoes, and others of the West India islands, adults are often- 
times attacked by it, with a degree of violence and obstinacy, which nothing 
but a change of climate can overcome. In Holland, Zealand, and other low 
and humid countries of the north of Europe, it is very common ; while in 
the warm and dry countries of the south, it is scarcely known. 

In this disease the eruptions generally make their appearance first about 
the angles of the lips, whence they spread to the inside of the lips, the 
tongue, the fauces, the oesophagus, and the whole alimentary canal ; until 
they ultimately appear even without the anus. Their colour varies, from 
■white to yellow, and from yellow to brown. The latter colour indicates 
danger. 

The eruptions about the mouth, although sometimes preceded by fever, 
are generally, we believe, the elder symptom. Morbid irritation in the 
stomach and bowels always precedes the fever, and acts as its cause. 

Aphtha, by attacking the gums of children, sometimes produces a general 
caries of the teeth. This manifests the existence of a strong sympathetic 
connection between the teeth and the stomach — a position which we endea- 
voured to establish in our annotations on odontalgia. 

In the treatment of aphtha, the cleansing of the stomach and bowels, by 
emetics and cathartics, should constitute the first object of attention. As 
the natural tendency of the disease, however, is to diarrhoea, the drastic pur- 
gatives are of doubtful utility. Castor oil, rhubarb, magnesia, and some of 
the milder saline purgatives, are generally employed. Calomel is also ex- 
hibited, either alone or in combination with rhubarb, and proves, in many 
cases, a very valuable remedy. The cases wherein it is used being well se- 
lected, sve think it among the most useful that can be administered. 

It is in the commencement of the disease, before the aphthous eruption 
has passed into the stomach and bowels, that these remedies may be most 
usefully employed. During its whole continuance, however, the prima; viae 
must be kept free from irritating contents : for if, by their morbific impres- 
sion, such contents originally produce the complaint, they must certainly 
aggravate it, and render it more obstinate, when it is already in existence. 
But, when the disease is at its height, injections are recommended in pre- 
ference to cathartics administered by the mouth. The reason assigned is, 
the clanger of inducing, by the use of purgatives, a debilitating and unmanage- 
able hypercatharsis. 

Towards the close of the disease, when the aphthous crusts are beginning 
to fall off, purgatives are again recommended, with a view to their removal 
from the alimentary canal. 



424 PRACTICE OF PHYSIC. 

does not belong to this place. The other is the Urti 
caria of our Synopsis, which, as taken into every sys- 
tem of Nosology as one of the Exanthemata Febrilia, is 
properly to be treated of here. 

730. I have never observed this disease as contagious 
and epidemic; and the few sporadic cases of it which 
have occurred to me, have seldom taken the regular 
course described by authors. At the same time, as the 
accounts of different authors are not very uniform, and 
hardly consistent, I cannot enter further into the consi- 
deration of this subject: and I hope it is not very neces- 
sary, as on all hands it is agreed to be a mild disease, 
and such as seldom requires the use of remedies. It is 
generally sufficient to observe an antiphlogistic regimen, 
and to keep the patient in a temperature that is neither 
hot nor cold. 

731. The Pemphigus, or Vesicular Fever, is a rare 
and uncommon disease, and very few instances of it are 
recorded in the writings of physicians. As I have never 
had occasion to see it, it would be improper for me to 
treat of it; and I do not choose to repeat after others, 
while the disease has yet been little observed, and its 

As the alimentary canal is known to sympathize very powerfully with the 
skin, gentle diaphoretics are advantageously administered in the treatment 
of aphtha. 

Magnesia, as an absorbent and gentle evacuant, is also recommended as 
particularly useful. It not only neutralizes the acid which usually super- 
abounds in the prima: vise, but converts it into a means of removing from 
the bowels what, would otherwise prove offensive. 

The diet should be nutritive, but entirely liquid, mucilaginous, and mild 
It may consist of well boiled sago, tapioca, powdered arrow-root, or barley 
water. Flax-seed tea ami gum arable dissolved in water make suitable 
drinks. 

As milk of bad qualities contributes to the production of aphtha in infants, 
fresh and wholesome milk, on the other hand, constitutes, when the fever ia 
not too violent, an exceedingly valuable article of diet. 

Those readers who wish to be more fully informed on the subject of this 
disease, are referred to Dr. Wilson's able and elaborate article on " aphthous 
fever." 



PRACTICE OF PHYSIC. 425 

character does not seem to be exactly ascertained. 
Vid. Acta Helvetica, vol. ii. p. 260. Synops. Nosolog. 
vol. ii. p. 149. 

732. The Aphtha, or Thrush, is a disease better 
known; and, as it commonly appears in infants, it is so 
well understood, as not to need our treating of it here. 
As an idiopathic disease, affecting adults, I have not 
seen it in this country: but it seems to be more frequent 
in Holland; and, therefore, for the study of it, I refer 
to Dr. Boerhaave, and his commentator Van Swieten, 
whose works are in every body's hands. 

733. The Petechia has been, by all our Nosologists, 
enumerated amongst the exanthemata; but as, accord- 
ing to the opinion of most physicians, it is very justly 
held to be always a symptomatic affection only, I can- 
not give it a place here. 



vol. i. 3 H 



126 PRACTICE OF PHYSIC. 



BOOK IV. 

OF BUEMORKHAGIES. 

CHAPTER I. 
OF FLEMORRFIAGY IN GENERAL. 

734. IN establishing a class or order of diseases under 
the title of Hcemorrhagics, Nosologists have employed 
the single circumstance of an effusion of red blood, as 
the character of such a class or order. By this means 
they have associated diseases which in their nature are 
very different; but, in every methodical distribution, 
such arbitrary and unnatural associations should be 
avoided as much as possible. Further, by that manage- 
ment Nosologists have suppressed or lost sight of an 
established and well-founded distinction of hamiorrha- 
gies into Active and Passive.* 

* The division of Haemorrhagies into " active and passive," recognized by 
our author in this article, is utterly unfounded, and ought to be rejected 
from pathological science. The phraseology leads to a physiological error. 
The expression "passive haemorrhagy," as applied to living matter, is a 
gross misnomer. During life, no haemorrhagy can possibly be passive. 
Blood flows from the vessel that contains it, at least in part, by means of the 
action of that vessel. Nor is it possible for such action to cease, otherwise 
than by the cessation of life in the part. But the cessation of life is the 
■commencement of gangrene. A haemorrhagy really passive, therefore, can- 
not take place except from gangrenous vessels. But from such vessels, 
unless they be very large, blood does not flow at all. The reason is obvious. 
They act on the blood which they contain like dead matter : and we well 
know that the action of dead matter on blood forces it to coagulate. Hence, 
in the vessels of a gangrenous part, the blood does coagulate, and prevents 
the hjemorrhagy that would otherwise ensue. 
Every haemorrhagy, therefore, that does or can take place from the living 



PRACTICE OF PHYSIC. 427 

735. It is my design to restore this distinction; and 
I shall therefore here, under the title of Haemorrhages, 
comprehend those only which have been commonly 
called Active, that is, those attended with some degree 
of pyrexia; which seem always to depend upon an in- 
creased impetus of blood in the vessels pouring it out, 
and which chiefly arise from an internal cause. In this 
I follow Dr. Hoffman, who joins the active haemorrha- 
gies with the febrile diseases, and have accordingly 
established these hagmorrhagies as an order in the 
class of Pyrexia. From this order I exclude all those 
effusions of red blood that are owing entirely to exter- 
nal violence; and all those which, though arising from 
internal causes, are however not attended with pyrexia, 
and which seem to be owing to a putrid fluidity of the 
blood, to the weakness or to the erosion of the vessels, 
rather than to any increased impetus of the blood in 
them. 

736. Before proceeding to treat of those proper hae- 
morrhagies which form an order in our Nosology, I 
shall treat of active hasmorrhagy in general; and indeed 
the several genera and species to be treated of particu- 
larly afterwards have so many circumstances in corn- 



body, is really an active one. It arises, not from the absolute want of action, 
in the part ; but from its wrong action. The vessels dilate, or rather con- 
tract and dilate alternately, when they ought to contract only, and thus pre- 
vent the escape of the blood which they contain. 

But some hxmorrhagies are attended with more action than others. 
Some have a much more general aspect than others. Some are febrile, 
others not. 

Instead, then, of being denominated active and passive, they might, in 
our estimation, be much more correctly divided into tonic and atonic- or, if 
we might be permitted to coin terms more suitable to the occasion, into 
pyrectic and apyrcctic- 

Tonic or pyrectic hxmorrhagy appears to be the very reverse of inflam- 
mation The latter consists in a deficiency, the former in an excess, of ac- 
ion in 'ho ypsseNof the part affected. 



1-28 PRACTICE OF PHYSIC. 

inon with one another, that the genera] consideration 
to be now offered will prove both proper and useful. 

Sect. I. — Of the Phenomena of Hcemorrhagy. 

737. The phenomena of haemorrhagy arc generally 
the following. 

Haemorrhagies happen especially in plethoric habits, 
and to persons of a sanguine temperament. They ap- 
pear most commonly in the spring, or in the beginning 
of summer. 

For some time, longer or shorter in different cases, 
before the blood flows, there are some symptoms of 
fulness and tension about the parts from whence the 
blood is to issue. In such parts as fall under our view, 
there are some redness, swelling and sense of heat or of 
itching ; and in the internal parts from which blood is to 
flow, there is a sense of weight and heat; and, in both 
cases, various pains are often felt in the neighbouring 
parts.* 

738. When these symptoms have subsisted for some 
time, some degree of a cold stage of pyrexia comes on, 
and a hot stage is formed; during which, the blood 
flows of a florid colour, in a greater or lesser quantity, 
and continues to flow for a longer or shorter time; but 
commonly, after some time, the effusion spontaneously 
ceases, and together with it the pyrexia also. 

739. During the hot stage which precedes an hae- 
morrhagy, the pulse is frequent, quick, full, and often 
hard; but as the blood flows, the pulse becomes softer 
and less frequent. 

740. In ha3morrhagies, blood drawn from a vein does, 



* To the symptoms announcing the approach of haemorrhagy from any 
part of the body, our author should have added, a sense of throbbing, or pul- 
sation, in the vessels from which the blood is to flow. 



PRACTICE OF PHYSIC. 429 

upon its concreting, commonly show the gluten sepa- 
rated, or a crust formed, asin the cases of Phlegmasia?. 
741. Haemorrhagies from internal causes, having 
once happened, are apt, after a certain interval, to re- 
turn-, in some cases very often, and frequently at stated 
periods* 

* That haemorrhagies recur periodically, is a fact, which will not, we pre- 
sume, be, at present, called in question. Nor is it, in reality, less true, al- 
though a matter of much less notoriety, that such recurrence corresponds 
very accurately, at least in many instances, to the periods of the moon. 

For no inconsiderable amount of curious information on this subject, our 
readers are referred to the writings of Dr Mead ; particularly his well 
known and very learned treatise, " De imperio Solis el Lun<e." 

To the more recent writings of Dr. Moseley, we are also indebted foP 
much information touching the influence of the moon on hxmorrhagies 

" The haemorrhagies from the lungs," says this author, " or those of ple- 
thora, like all periodical haemorrhagies, undisturbed in their natural course 
by peculiar circumstances, obey the influence of the moon. Of this I have 
many proofs ; and that there are not more, authenticated by others, is owing, 
I believe, to the theory on which the fact depends not being sufficiently 
known to prevent the result escaping unnoticed. 

"Among the many instances which I have lately seen, there was one 
which deserves to be recorded. A man in Burleigh-street, in the Strand, 
had a cough for some time, which brought on a haemoptysis. This continued 
for six weeks, and then degenerated into a regular monthly eruption of 
blood from the lungs. He disgorged about eight ounces of blood from the lungs 
every full moon. 

" This doctrine attended to," continues our author, " haemorrhagies 
which do not prove fatal in the first or second attack, will seldom be 
so afterwards; as their returns may always be moderated, and often en- 
tirely prevented; which, from repeatedly wounding the lungs, induce ulce- 
ration there, and end the subject in consumption." 

In further confirmation of the doctrine of the influence of the moon in the 
production of haemorrhagies, Dr. Moseley narrates the following very re^ 
markable and pertinent case. « 

*' Captain Richard Boyle, of the third regiment of guards, was attacked in 
London, on the 20th of January, 1785, from straining in pulling on his boots, 
with a pulmonary haemorrhage, and almost suffocated by the violence of the 
blood forcing itself through his mouth and nostrils. It was preceded by a 
momentary tickling in his throat, that excited a fit of coughing; in which 
an artery burst in the right lobe of his lungs. He was in the 23d year of his 
age, and of a plethoric habit; but free from defect in make, that might indi- 
cate such an event. 

" He had many repetitions of the haemorrhage, after recovering from the 
first, in the course of the same year; and was advised to go to the south of 
France, to avoid the following winter in England. It was there that I saw 



430 PRACTICE OF PHYSIC. 

742. These are, in general, the phenomena of hae- 
morrhage; and if, in some cases, all ol them be not ex- 
quisitely marked, or if perhaps some of them do not at 
all appear, it imports only, that, in different cases, the 
system is more or less generally affected ; and that, in 
some cases, there are purely topical haemorrhagies, as 
there are purely topical inflammations. 

Sect. II. — Of the Proximate Cause of Hcemorrhagy. 

743. The pathology of haemorrhagy seems to be suf- 
ficiently obvious. Some inequality in the distribution 
of the blood occasions a congestion in particular parts 
of the sanguiferous system; that is, a greater quantity of 
blood is poured into certain vessels than their natural 
capacity is suited to receive. These vessels become 

him; and found the hemorrhage periodical; and so faithfully obeyed the in- 
fluence of the moon, that a statement of the returns of such as came within 
knowledge, will show one of the most decisive examples of lunar influence 
in medical history. 

" 1786, February 14th, he was attacked at Hieres near Toulon — Full moon 
on the 13th. In this haemorrhage, he was for some time thought, by his at- 
tendants, to be dead. 

" February 20th, at Mx, in Provence. New moon on the 28th. Here, 
also, he bled nearly to death. 
" April 15th, at ditto. Full moon on the 13th. 
" April 29th, at Tain, upon the Rhone. New moon on the 28th 
" May 14th, at Chalons in Burgundy Full moon on the 13th. 
" June 11th, at Dijon. It was then full moon. 
" July 11th, at Paris. It was then full moon. 

" August 9th, at Yarmouth, in the Isle of Wight. It was then full moon. 
" The three last haemorrhages came on at the instant the moon appearec' 
above the horizon." 

On many other occasions, in the case of captain Boyle, did the haemor 
rhagy from the lungs appear, at the time of the full or change of the moon, 
with as much punctuality as in those we have recited. 

Readers who may wish further to amuse themselves with many curious, 
and not uninteresting facts and speculations, touching the influence of the 
moon, not only in haemorrhagies, but on various other diseases, will be grati- 
fietl by looking into the writings of Moseley, Mead, Ramazzini, Diemer- 
broeck Ballonius, Van Helmont, Sennertus, Lord Bacon, Ambrose Pi 
and many other authors of prior date. 



PRACTICE OF PHYSIC, 431 

thereby preternaturally distended; and this distention, 
proving a stimulus to them, excites their action to a 
greater degree than usual, which, pushing the blood 
with unusual force into the extremities of these vessels, 
opens them by anastomosis, or rupture; and, if these 
extremities be loosely situated on external surfaces, or 
on the internal surfaces of certain cavities that open out- 
wardly, a quantity of blood flows out of the body.* 

744. This reasoning will, in some measure, explain 
the v production of haemorrhagy. But it appears to me, 
that, in most cases there are some other circumstances 
that concur to produce it; for it is probable, that, in con- 
sequence of congestion, a sense of resistance arises, and 
excites the action of the vis medicatrix naturse, the ex- 
ertions of which are usually made by the formations of 
a cold stage of pyrexia, inducing a more vigorous action 
of the vessels; and the concurrence of this exertion 
more effectually opens the extremities, and occasions 
the flowing out of the blood. 

745. What has been delivered in the two preceding 
paragraphs, seems to explain the whole phenomena of 
haemorrhagy, except the circumstance of its frequent re- 
currence, which I apprehend may be explained in the 
following manner. The congestion and consequent irri- 

* This inequality is oftentimes produced, by that irregularity in the dis 
tribution of the blood, which is requisite for the promotion of the growth 
of the parts. When the bones of the face, for example, are acquiring their 
ultimate expansion, they receive, for their nourishment, a larger portion of 
blood, than they did at any former period, or than they do for their mere 
subsistence, after they have attained to their full size The same thing is 
true in relation to the lungs. Nor is it probable that the vessels of a part at- 
tain their entire strength as soon as their growth is completed. The younger 
they are, the more easily may they be lacerated. They acquire their size 
first, and their strength and power of resistance, afterwards. These facts 
may account, perhaps, in part, for the frequency of epistaxis and hemopty- 
sis, about the age of puberty, when the bones of the face and the thorax, 
with its contents, are acquiring their full size, with a progress more thai 
usually rapid. 



432 PRACTICE OF PHYSIC. 

tation being taken off by the flowing of the blood; this 
therefore, soon after, spontaneously ceases; but, at the 
same time, the internal causes which had before pro- 
duced the unequal distribution of the blood, commonly 
remain, and must now operate the more readily, as the 
over-stretched and relaxed vessels of the part will more 
easily admit of a congestion of blood in them, and, con- 
sequently, produce the same series of phenomena as 
before. 

746. This may sufficiently explain the ordinary return 
of haemorrhagy; but there is still another circumstance, 
which, as commonly concurring, is to be taken notice 
of; and that is, the general plethoric state of the system, 
which renders every cause of unequal distribution of 
more considerable effect. Though haemorrhagy may 
often depend upon the state of the vessels of a particu- 
lar part being favourable to a congestion's being formed 
in them; yet, in order to that state's producing its effect, 
it is necessary that the whole system should be at least 
in its natural plethoric condition; and, if this should be 
in any degree increased beyond what is natural, it will 
still more certainly determine the effects of topical con- 
formation to take place. The return of haemorrhagy, 
therefore, will be more certainly occasioned, if the sys- 
tem becomes preternaturally plethoric; but haemorrhagy 
has always a tendency to increase the plethoric slate 
of the system, and, consequently, to occasion its own 
return. 

747. To show that hasmorrhagy does contribute to 
produce or increase the plethoric state of the system, it 
is only necessary to observe, that the quantity of serous 
fluids being given, the state of the excretions depends 
upon a certain balance between the force of the larger 
arteries propelling the blood, and the resistance of the 
excretories: but the force of the arteries depends upon 



PRACTICE OF PHYSIC. 433 

their fulness and distention, chiefly given to them by the 
quantity of red globules and gluten, which are for the 
greatest part confined to the red arteries; and therefore, 
the spoliation made by an hfemorrhagy, being chiefly of 
red globules and gluten, the effusion of blood must leave 
the red arteries more empty and weak. In consequence 
of the weaker action of the red arteries, the excretions 
are in proportion diminished; and, therefore, the ingesta 
continuing the same, more fluids will be accumulated 
in the larger vessels. It is by this means that the loss 
of blood by haemorrhagies, whether artificial or sponta- 
neous, if within certain bounds, is commonly so soon: 
recovered: but as the diminution of the excretions, from 
a less quantity of fluid being impelled into the excreto- 
ries, gives occasion to these vessels to fall into a con- 
tracted state-, so, if this shall continue long, these ves- 
sels will become more rigid, and will not yield to the 
same impelling force as before. Although the arteries, 
therefore, by new blood collected in them, shall have re- 
covered their former fulness, tension, and force; yet this 
force will not be in balance with the resistance of the 
more rigid excretories, so as to restore the former state 
of excretion; and, consequently, a further accumulation 
will take -place in the arteries, and an increase of their 
plethoric state be thereby induced. In this manner, we 
perceive more clearly, that hajmorrhagy, as producing a 
more plethoric state of the system, has a tendency to oc- 
casion its own recurrence with greater violence; and, as 
the renewal and further accumulation of blood require 
a determinate time, so, in the several repetitions of ha3- 
morrhagy, that time will be nearly the same; and there- 
fore the returns of haemorrhagy will be commonly at 
stated periods, as has been observed frequently to 
happen. 

748. I have thus explained the nature of hasmor- 

vol. i 3 T 



434 PRACTICE OF PHYSIC. 

rhagy in general, as depending upon some inequality in 
the distribution of the blood, occasioning a congestion 
of it in particular parts of the sanguiferous system. It 
is indeed probable, that, in most persons, the several 
parts of the sanguiferous system are in balance with 
one another; and that the density, and consequently the 
resistance, in the several vessels, is in proportion to the 
quantity of blood which each should receive; from 
whence it frequently happens, that no inequality in the 
distribution of blood takes place in the course of a long 
life. If, however, we consider that the sanguiferous 
system is constantly in a plethoric state, that is, that the 
vessels are constantly distended beyond that size which 
they would be of, if free from any distending force, we 
shall be satisfied that this state may be readily changed. 
For as, on the one hand, the vessels are elastic, so as 
to be under a constant tendency to contract upon the 
withdrawing of any part of the distending force; and, 
on the other hand, are not so rigid, but that, by an in- 
crease of the impetus of the blood in them, they may 
be more than ordinarily distended; so we can easily un- 
derstand how, in most persons, causes of an increased 
contraction or distention may arise in one part or other 
of the system, or that an unequal distribution may take 
place; and how, in an exquisitely distended or plethoric 
system, a small inequality in the distribution of the 
blood may form those congestions which give occasion 
to hasmorrhagy. 

749. In this manner I endeavour to explain how hse- 
morrhagy may be occasioned at any period of life, or in 
any part of the body: but haemorrhagies happen in cer- 
tain parts more frequently than in others, and at certain 
periods of life more readily than at others; and there- 
fore, in delivering the general doctrine of haemorrhagy. 
it may be required that I should explain those circum 



PRACTICE OF PHYSIC. 435 

stances which produce the specialities mentioned; and 
I shall now attempt it. 

750. The human body, from being of a small bulk 
at its first formation, grows afterwards to a considera- 
ble size. This increase of bulk consists, in a great 
measure, in the increase of the quantity of fluids, and 
a proportional enlargement of the containing vessels. 
But, at the same time, the quantity of solid matter is 
also gradually inereased; and, in whatever manner we 
may suppose this to be done, it is probable that the pro- 
gress, in the whole growth of animal bodies, depends 
upon the extension of the arterial system; and such is 
the constitution of the sanguiferous system, that the 
motion of the blood in the arteries has a constant ten- 
dency to extend them in every dimension.** 

751. As the state of the animal solid is, at the first 
formation of the body, very lax and yielding; so the ex- 
tension of the system proceeds, at first, very fast: but, 
as the extension gives occasion to the apposition of 
more matter to the solid parts, these are, in proportion 
to their extension, constantly acquiring a greater den- 
sity, and therefore giving more resistance to their fur- 
ther extension and growth. Accordingly, we observe, 
that as the growth of the body advances, its increase, 
in any given time, becomes proportionally less and less, 
till at length it ceases altogether. 

752. This is the general idea of the growth of the 

* Animal growth does not consist in mere extension. It is impossible, by 
that process, ever to form large arteries out of small ones. It consists in 
absorption and apposition. The absorbents remove entirely the smaller ar- 
teries, while the vessels destined for the promotion of growth, lay down 
larger and stronger ones in their places. On no other principles can the 
growth of animal parts be explained Nor is it true, that the growth of the 
body is always rapid, in proportion as the vessels are lax and tender. We 
sometimes observe youth to grow more rapidly from sixteen to nineteen, or 
even from seventeen to twenty-one, than at any former period. Our author's 
doctrine is too coarse and mechanical to be true 



436 PRACTICE OF PHYSIC. 

human body, till it attain the utmost bulk which it is 
capable of acquiring: but it is "to be remarked, that this 
growth does not proceed equally in every part of the 
body, it being requisite for the economy of the system, 
that certain parts should be first evolved, and should 
also acquire their full bulk sooner than others. This 
appears particularly with respect to the head, the parts 
of which appear to be first evolved, and soonest to ac- 
quire their full size. 

753. To favour this unequal growth, it is presumed, 
that the dimensions or the laxity of the vessels of the 
head, or that the direction of the force of the blood, are 
adapted to the purpose; and from what has been said 
in 751, it will also certainly follow, that as the vessels 
of the head grow fastest, and soonest acquire their full 
size, so they will soonest also acquire that density which 
will prevent their further extension. While, however, 
the force of the heart, and the quantity of the fluids, 
with respect to the whole system, remain the same, the 
distending and extending powers will be directed to 
such parts as have not yet acquired the same density 
and dimensions as those first evolved; and thus the 
distending and extending powers will proceed to ope- 
rate till every part of the system, in respect of density 
and resistance, shall have been brought to be in balance 
with every other, and till the whole be in balance 
with the force of the heart, so that there can be no 
further growth in any particular part, unless some pre- 
ternatural circumstance shall happen to arise. 

754. In this process of the growth of the body, as it 
seems in general to depend upon a certain balance be- 
tween the force of the heart or distending power, and 
the resistance of the solids; so it will appear, that, while 
the solids remain very lax and yielding, some occasional 
increase of the distending power may arise without 



PRACTICE OF PHYSIC. 437 

producing any very perceptible disorder in the system. 
But, it will also appear, that, in proportion as the dis- 
tending power and resistance of the solids come to be 
more nearly in exact balance with one another, so any 
increase of the distending power will more readily pro- 
duce a rupture of vessels, which do not easily yield to 
extension. 

755. From all this, it must follow, that the effects of 
an unusually plethoric state of the system will be dif- 
ferent, according as this shall occur at different periods 
of the growth of the body. Accordingly it is evident, 
that if the plethoric state arises while the head is yet 
growing, and while the determination of the blood is 
still more to the head than to the other parts, the in- 
creased quantity of the blood will be especially deter- 
mined to the head; and as there also, at the same time, 
the balance between the distending and extending 
powers is most nearly adjusted, so the determination 
of the blood will most readily produce in that part a 
rupture of the vessels, or an hasmorrhagy. Hence it 
is, that hasmorrhagies of the nose so frequently happen 
to young persons; and in these more readily, as they 
approach nearer to their acme, or full growth; or, it 
may be said, perhaps more properly, as they approach 
nearer to the age of puberty, when, perhaps, in both 
sexes, but especially in the female, a new determina- 
tion arises in the system. 

756. The determination of a greater quantity of blood 
to the vessels of the head, might be supposed to occa- 
sion a rupture of vessels in other parts of the head, as 
well as in the nose: but such a rupture does not com- 
monly happen; because in the nose there is, for the pur- 
pose of sense, a considerable net-work of blood-vessels 
expanded on the internal surface of the nostrils, and 
covered only with thin and weak teguments. From this 



438 PRACTICE OF PHYSIC. 

circumstance it is, that upon any increased impetus of 
the blood in the vessels of the head, those of the nose 
are most easily broken; and the effusion from the nose 
taking place, it not only relieves the other extremities 
of the external carotid, to which the arteries of the nose 
chiefly belong, but relieves also, in a great measure, the 
system of the internal carotid. For, from the internal 
carotid, certain branches are sent to the nose, are spread 
out in its internal surface, and probably inosculated 
with the extremities of the external carotid: so that, 
whichsoever of the extremities are broken, the vis 
derivationis of Haller will take place; the effusion will 
relieve the whole sanguiferous system of the head, and 
the same effusion will also commonly prevent an ha> 
morrhagy happening at the same time in any other part 
of the body. 

757. From these principles, it will appear why has- 
morrhagies of the nose, so frequent before the period 
of puberty, or of the acme, seldom happen after these 
periods: and I must observe further, that although they 
should occur, they would not afford any objection to 
my doctrine, as such haemorrhagies might be imputed 
to a peculiar laxity of the vessels of the nose, and per- 
haps to a habit acquired with respect to these vessels, 
while the balance of the system might be otherwise duly 
adjusted. 

758. When the process of the growth of the body 
goes on regularly, and the balance of the system is pro- 
perly adjusted to the gradual growth of the whole, as 
well as to the successive growth of the several parts, 
even a plethoric state does not produce any hsemorrha- 
gy, or at least any after that of the nose: but if, while 
the plethoric state continues, any inequality shall also 
subsist in any of the parts of the system, congestions, hae- 
morrhagic or inflammatory, may be still readily formed. 



PRACTICE OF PHYSIC. 439 

759. In general, it may be observed, that, when the 
several parts of the system of the aorta have attained 
their full growth, and are duly balanced with one 
another, if then any considerable degree of plethora re- 
main or arise, the nicety of the balance will be between 
the systems of the aorta and pulmonary artery, or be- 
tween the vessels of the lungs and those of all the rest 
of the body. And although the lesser capacity of the 
vessels of the lungs is commonly compensated by the 
greater velocity of the blood in them; yet, if this velo- 
city be not always adjusted to the necessary compen- 
sation, it is probable that a plethoric state of the whole 
body will always be especially felt in the lungs; and, 
therefore, that an haemorrhagy, as the effect of a gene- 
ral plethora, may be frequently occasioned in the lungs, 
even though there be no fault in their conformation.* 

760. In some cases, perhaps, an haemorrhagy from 
the lungs, or an haemoptysis, does arise from the gene- 
ral plethoric state of the body; but an haemoptysis more 
frequently does, and may be expected to happen, from 
a faulty proportion between the capacity of the lungs 
and that of the rest of the body. 

761. When such a disproportion takes place, it will 
be evident, that an haemoptysis will especially happen 
about the time that the body is approaching to its 
acme; that is, when the system of the aorta has arrived 
at its utmost extension and resistance, and when, there- 
fore, the plethoric state of the whole must especially 
affect the lungs. 

762. Accordingly, it has been constantly observed, 
that the haemoptysis especially occurs about the time of 
the body's arriving at its acme; but I must remark also, 

* We recollect, at present, no facts or experiments, tending to show, that 
the blood moves through the pulmonary system with greater velocity, than 
in the other parts of the bodv. 



440 PRACTICE OF PHYSIC. 

that the haemorrhagy may occur sooner or later, ac- 
cording as the balance between the vessels of the lungs 
and those of the system of the aorta, happens to be 
more or less exactly adjusted to one another; and it 
may, therefore, often occur much later than the period 
mentioned, when that balance, though not quite even, 
is, however, not so ill adjusted, but that some other con- 
curring causes are necessary to give it effect. 

763. It was anciently remarked by Hippocrates, and 
has been confirmed by modern observation, that the 
haemoptysis generally occurs in persons between the 
age of fifteen and that of five-and-thirty; that it may 
happen at any time between these two periods; but that 
it seldom happens before the former, or after the latter; 
and it may be proper here to inquire into the reason of 
these two limitations. 

764. With respect to the first, the reason of it has 
been already explained in 761. and 762. 

With respect to the second limitation, I expect that 
the reason of it will be understood from the following 
considerations. 

It has been already observed, that the extension and 
growth of the body require the plethoric state of the ar- 
terial system; and nature has provided for this, partly 
by the constitution of the blood being such that a great 
proportion of it is unfit to pass into the exhalants and 
excretories; partly by giving a certain density and re- 
sistance to the several exhalants and excretories through 
which the fluids might pass out of the red arteries; and 
partly, but especially, by a resistance in the veins to 
the free passage of the blood into them from the ar- 
teries. 

765. With respect to this last and chief circum- 
stance, it appears from the experiments of Sir Clifton 
Wintringham, in his Experimental Inquiry, that the 



PRACTICE OF PHYSIC. 441 

proportional density of the coats of the veins to that of 
the coats of the arteries, is greater in young than in old 
animals: from which it may be presumed, that the re- 
sistance to the passage of the blood from the arteries 
into the veins, is greater in young animals than in old ; 
and, while this resistance continues, the plethoric state 
of the arteries must be constantly continued and sup- 
ported. As, however, the density of the coats of the ves- 
sels, consisting chiefly of a cellular texture, is increased 
by pressure; so, in proportion as the coats of the arte- 
ries are more exposed to pressure by distention than 
those of the veins, the former, in the progress of the* 
growth of the body, must increase much more in den- 
sity than the latter; and, therefore, the coats of the ar- 
teries, in respect of density and resistance, must come, 
in time, not only to be in balance with those of the veins, 
but to prevail over them ; a fact which is sufficiently 
proved by the experiments of the above-mentioned in- 
genious author. 

By these means, the proportional quantities of b'ood 
in the arteries and veins must change in the course of 
life. In younger animals the quantity of blood in the 
arteries must be proportionally greater than in old 
ones; but by the increasing density of the arteries, 
the quantity of blood in them must be continually di- 
minishing, and that in the veins be proportionally in- 
creasing, so as at length to be in a proportionally greater 
quantity than that in the arteries. When this change 
happens in the proportional quantities of the blood in 
the arteries and veins, it must be evident that the ple- 
thoric state of the arteries will be in a great measure 
taken off; and therefore that the arterial ha?morrhagy 
is no longer likely to happen; but that if a general ple- 
thoric state afterwards take place in the system it must 
especially appear in the veins. 

vol. i. 3 k 



PRACTICE Oi PHYSH 

766. The change I have mentioned to happen in the 
state of the arterial and venous systems, is properly sup 
posed to take place in the human body about the age of 
thirty-five, when it is manifest that the vigour of tin- 
body, which depends so much upon the fulness and 
tension of the arterial system, no longer increases; and 
therefore it is, that the same age is the period after which 
the arterial haemorrhagy, haemoptysis, hardly ever ap- 
pears. It is true, there are instances of the haemopty- 
sis happening at a later period; but it is for the reasons 
given (757.) which show that an hcemorrhagy may hap- 
pen at any period of life, from accidental causes form- 
ing congestions, independent of the state of the balance 
of the system at that particular period. 

767. 1 have said (765.) that if, after the age of thirty- 
five, a general and preternatural plethoric state occur, it 
must especially appear in the venous system; and I must 
now observe, that this venous plethora may also give 
occasion to haemorrhagy. 

768. If a plethoric state of the venous system take 
place, it is to be presumed, that it will especially and in 
the first place affect the system of the vena portarum, 
in which the motion of the venous blood is more slow 
than elsewhere; in which the motion of the blood is 
little assisted by external compression; and in which, 
from the want of valves in the veins that form the vena 
portarum, the motion of the blood is little assisted by 
the compression that is applied; while, from the same 
want of vahes in those veins, the blood is more ready 
to regurgitate in them. Whether any regurgitation of 
the blood can produce an action in the veins, and which, 
inverted or directed towards their extremities, can force 
these, and occasion haemorrhagy, may perhaps be dis- 
puted: but it appears to me that an haemorrhagy, pro- 
duced by a plethoric state of the veins, may be ex- 



PRACTICE OF PHYSIC. 443 

plained in another and more probable manner. If the 
blood be accumulated in the veins, from an interrup- 
tion of its proper course, that accumulation must resist 
the free passage of the blood from the arteries into the 
veins. This again must produce some congestion in 
the extremities of the red arteries, and therefore some 
increased action in them, which must be determined 
with more than usual force, both upon the extremities 
of the arteries, and upon the exhalants proceeding from 
them; and this force may occasion an effusion of blood, 
either by anastomosis or rupture. 

769. In this manner I apprehend the haemorrhoidal 
flux is to be explained, so far as it depends upon the 
state of the whole system. It appears most commonly 
to proceed from the extremities of haemorrhoidal ves- 
sels, which, being the most dependent and distant 
branches of those veins that form the vena portarum, 
are therefore the most readily affected by every accu- 
mulation of blood in that system of veins, and conse- 
quently by any general plethora in the venous system. 

770. It is here to be observed, that I have spoken of 
this haemorrhagy as proceeding from the haemorrhoidal 
vessels only, as indeed it most commonly does, but it 
will be readily understood, that the same accumulation 
and resistance to the venous blood may, from various 
causes, affect many of the extremities of the vena porta- 
rum, which lie very superficially upon the internal sur- 
face of the alimentary canal, and give occasion to what 
has been called the Morbus Niger or Melcena. 

771. Another part in which an unusually plethoric 
state of the veins may have particular effects, and oc- 
casion haemorrhagy, is the head. In this, the venous 
system is of a peculiar conformation, and such as seems 
intended by nature to give there a slower motion to the 
venous blood. If, therefore, the plethoric state of the 



444 PRACTICE OF PHYSK 

venous system in general, which seems to increase as 
life advances, should at length increase to a great de- 
gree, it may very readily affect the venous vessels of the 
head, and produce there such a resistance to the arterial 
blood, as to determine this to be poured out from the 
nose, or into the cavity of the cranium. The special 
effect of the latter effusion will be, to produce the dis- 
ease termed Apoplexy ; and which, therefore, is pro- 
perly named by Dr. Hoffman, Hcemorrhagia Cerebri: 
and the explanation of its cause, which I have now 
given, explains well why it happens especially to men 
of large heads and short necks, and to men in the decline 
of life, when the powers promoting the motion of the 
blood are much weakened.* 

772. I have tlius attempted to give the history of the 
plethoric and hasmorrhagic states of the human body, 
as they occur at the different periods of life; and hope 
I have thereby explained, not only the nature of hse- 

* We do not believe that apoplexy is ever produced, in the manner 
stated in this article. It is certainly, in most cases, if not always, a gastric 
disease, the brain being only secondarily affected. Hence it is, that, in 
those predisposed to it, it is so often excited by a meal inordinately full, 
or consisting of materials crude and indigestible, a debauch in drinking, or 
any other cause that produces a morbid and strong impression on the 
stomach. Those cases of apoplexy which arise from the passions of the 
mind, are the only ones perhaps that have not a gastric origin. 

Notwithstanding the acuteness of perception, and ingenuity of reason- 
ing, which our author has displayed, in his inquiry respecting the proximate- 
cause of haemorrhagy, the entire section wherein it is contained is little 
else but an elaborate and intricate tissue of error. In all the essential 
qualities of inconclusiveness, it is ©n a level with his theories of inflamma- 
tion and fever. 

We regret our inability to offer any thing new or satisfactory on this sub • 
ject. A correct theory of hxmorrhagy constitutes a desideratum in the 
science of pathology. That desideratum, however, we shall not, at present, 
attempt to supply. 

Nor will our practical consideration of the disease be found to suffer ma- 
terially from the want of it. For, here, as in other instances, correct prac- 
tice is not the result of theory, but experience. However satisfactory- 
'.herefore, a rational theory might be, to the philosopher, it is not, in the. 
strict interpretation of the term, essential to the practitioner. 



PRACTICE OF PHYSIC. US 

morrhagy in general, but also of the particular hsemor- 
rhagies which commonly appear, and as they occur 
successively at the different periods of life. 

Sect. HI. — Of the Remote Causes of Hceinorrhagy. 

i 

773. In the explanation hitherto given, I have espe- 
cially considered the predisposition to haemorrhagy: 
but it is proper also, and even necessary, to take notice 
of the occasional causes, which not only concur with 
the predisponent, in exciting haemorrhagy, but may 
also sometimes be the sole cause of it. 

774. These occasional causes are, 

1. External heat, which, by rarefying the blood, pro- 
duces or increases the plethoric state of the body; and 
the same heat, as giving a stimulus to the whole system, 
must urge any particular determinations before esta- 
blished, still further, or may urge to excess any inequa- 
lity, otherwise innocent; so that, in either way, exter- 
nal heat may immediately excite haemorrhagies, to 
which there was a predisposition; or may form conges- 
tions where there were none before, and thereby occa- 
sion haemorrhagy.* 

* External heat does not rarefy the blood. It only appears to rarefy it, in 
consequence of eliciting it towards the surface of the body, and the extre- 
mities, by means of its stimulant impression ; thus giving-, to these parts, a 
visible turgescence which they did not before possess. 

In the production of hsemorrhagy, therefore, external heat operates in a 
two-fold way. It increases the force and rapidity of the general circulation, 
and produces a local congestion, in superficial vessels, where it did not pre- 
viously exist. From the former effect may arise haemorrhagies, either ex- 
ternal or internal ; from the latter, external haemorrhagies only. 

We, not long since, saw a female discharge, from her mouth, we believe 
it ci»me from the fauces, a considerable portion of blood, in consequence of 
a violent paroxysm of anger. 

Parts of the body, whence blood is like to flow, or is actually flowing, 
should be kept, as far as possible, from a depending positron. Hence, in 
epistaxis, the body should be erect j and, in cases of uterine haemorrhagy, fe- 
males should not only lie in bed, but have their hips somewhat elevated 



<4b PRACTICE OF PHYSIC. 

2. A considerable and sudden diminution of the 
weight of the atmosphere, which seems to occasion the 
same effects as heat, by producing also an expansion ot 
the blood. 

3. Whatever increases the force of the circulation, 
and thereby the velocity of the blood, may operate in 
the same manner as heat, in urging not only previous 
determinations with violence, but also in urging to ex- 
cess inequalities, otherwise innocent. All violent exer- 
cise, therefore, and especially all violent efforts, which, 
not only by a larger and longer inspiration, but also by 
the simultaneous action of many muscles interrupting 
the free motion of the blood, impel it with unusual force 
into the extreme vessels more generally, and, according' 
to the different postures of the body, and mode of the 
effort, into certain vessels more particularly. 

Among the causes increasing the force of the circu- 
lation, anger and other violent active passions are to be 
reckoned. 

4. The violent exercise of particular parts of the body. 
If these are already affected with congestions, or liable 
to them, such exercise may be considered as a stimulus 
applied to the vessels of that particular part. Thus, any 
violent exercise of respiration may excite hasmoptysis, 
or occasion its return. 

5. The postures of the body increasing determina- 
tions, or ligatures occasioning accumulations of the 
blood in particular parts of the body. 

6. A determination into certain vessels rendered ha- 
bitual by the frequent repetition of haemorrhagy from 
them. 

7. Cold, externally applied, as changing the distribu- 



This latter position is also useful in the treatment of profuse barmorrhoidal 
discharges. 



PRACTICE OF PHYSIC. 447 

tion of the blood, and determining it in greater quantity 
into the internal parts. 

Sect. IV. — Of the Cure of Hccmorrhagy. 

775. Having thus considered the proximate and re- 
mote causes of haemorrhagy in general, our next business 
is, to treat of the cure of the disease in the same manner. 

In entering upon this subject, the first question which 
presents itself, is, Whether the cure of haemorrhagies 
ought to be attempted by art, or if they should be left 
to the conduct of nature? 

776. The latter opinion was the favourite doctrine of 
the celebrated Dr. Stahl, and his followers. They 
maintained that the human body is much disposed to a 
plethoric state; and, consequently, to many disorders 
which nature endeavours to obviate and relieve by ex- 
citing haemorrhagy: that this, therefore, is often neces- 
sary to the balance and health of the system: that it is 
accordingly to be generally encouraged, sometimes so- 
licited, and is not to be suppressed, unless when it goes 
to great excess, or happens in parts in which it may be 
dangerous. 

777. Much of this doctrine may be admitted. The 
human body, upon many occasions, becomes preter- 
naturally plethoric; and the dangerous consequences 
which might from thence be apprehended, seem to be 
obviated by an haemorrhagy taking place: and, further, 
the necessity of haemorrhagy often appears from hence, 
that the suppression of it seems to occasion many dis- 
orders. 

All this seems to be just; but, in the conclusion 
drawn from it, there is a fallacy. 

778. It appears to me certain, that haemorrhagy, 
either upon its first attack, or upon its first recurrence, 
is never necessary to the health of the body, excepting 



448 PRACTICE OF PHYSIC. 

upon the supposition, that the plethoric state which 
seems to require the evacuation, cannot be otherwise 
prevented or removed; and as I imagine it possible by 
other means to prevent or remove a plethoric state, so 
I do not think that haemorrhagy is, in all cases, neces- 
sary. In general, I am of opinion that haemorrhagy is 
to be avoided. 

1. Because it does not always happen in parts where 
it is safe. 

2. Because often, while it does relieve a plethoric 
state, it may, at the same time, induce a very dangerous 
disease. 

3. Because it may often go to excess, and either en- 
danger life, or induce a dangerous infirmity. 

And, lastly, Because it has a tendency to increase the 
plethoric state it was meant to relieve; to occasion its 
own recurrence, (120.) and thereby to induce a habit, 
which, if left to the precarious and unequal operation 
of nature, may, from the frequent errors of this, be at- 
tended with much danger. 

779. It is further to be considered, that hsemorrha- 
gies do not always arise from the necessities of the sys- 
tem, but often proceed from incidental causes. It ap- 
pears to me that all haemorrhagies of the latter kind 
may be immediately suppressed, and the repetition of 
them, as it induces a plethora, and a habit not other- 
wise necessary, may be prevented with great advantage. 

780. Upon the whole of this subject, I conclude, that 
every preternatural haemorrhagy, or, in other words, 
every one except that of the menses in females, is to be 
avoided, and especially the returns of it prevented; and 
I therefore now proceed to mention, how haemorrhagy, 
and its recurrences, may, and should be prevented. 

781. From the principles delivered above, it will im- 
mediately appear, that the prevention, either of the first 



PRACTICE OF PHYSIC. 449 

attacks, or of the returns of haemorrhagy, will chiefly, 
and in the first place, depend upon the preventing or re- 
moving any considerable degree of a plethoric state 
which may happen to prevail in the body. It is true, 
that, where the haemorrhagy depends upon the particu- 
lar conformation of certain parts, rather than upon the 
general plethoric state of the whole, the measures for 
removing or preventing the latter may not always be 
sufficient for preventing haemorrhagy : but at the same 
time it must be evident, that determinations, in conse- 
quence of the conformation of particular parts, will al- 
ways be urged more or less, in proportion to the greater 
or lesser degree of the plethoric state of the whole sys- 
tem; and therefore, that even in the cases depending 
upon particular conformation, the preventing or remov- ( 
ing an unusual plethoric state will always be a chief 
means of preventing haemorrhagy. It is further to be 
attended to, that there may be several inequalities in the 
balance of the system, which may have little or no 
effect unless when the system becomes preternaturally 
plethoric; and, therefore, that in all cases the prevent- 
ing or removing of the plethoric state of the system will 
be a chief means of preventing the first attacks, or the 
returns of haemorrhagy. It now therefore remains to 
explain, how the plethoric state of the system is to be 
prevented or removed. 

782. The fluids of the human body are in continual 
waste by the excretions, but are commonly replaced by 
the aliments taken in; and if the quantity of aliments 
in any measure exceed that of the excretions, an in- 
crease of the quantity of the fluids of the body, or, in 
other words a plethoric state, must necessarily arise. 
This, to a certain degree, is requisite for the growth of 
the body, but even then, if the proportion of the ali- 
ments to the excretions, be greater than is suited to the 

vol. i. 3 L 



450 PRACTICE OF PHYSIC. 

growth of the body, and more certainly still, if, alter the 
growth is completed, when an equality between the in- 
gesta and the excreta should be established, the dispro- 
portion still continue, a preternaturally plethoric state 
must arise. In both cases, it is evident that the plethora 
must be prevented or corrected by adjusting the ingesta 
and excreta to each other; which ge